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022-1006-80-105
-D 0 oo 0 C/) N O r m G d c (D m "o 3 ((D m .0 I Dl (D V/ A 1 1\ 1\ I 3 3 ~ ~ ~ N O O Cl C O CO Cn S j W N • 0 0 O O O (D N V co ~j N n' C O N r7a fD d d N c N O - 7c O ►+e co co o O p Q Q CD 7 O C, ° o C tp O O n z W A7 o O 7 N O ° cn 0 ~r m m 3 Q (n [ A 0 a 7 m N CD n N n co n d o w V 3 O o o n ~ W X o co oD a 000 0o z CA c c I o ~ z O O O• I o N y N N o' D _ Q avv cn C) O D) N N CA ~1 v z N zco z o D a CD 0 a o' CD (n • N (n t~l -1 cn C D i C CD CD W (D C1 a 3 z CD 1 N O (n O A Z CD J Z n A O m ° O 0 Z) Z w aov m00 (D z '0 3 o U) 3 m A < N CD N p~ CD (n =i CD CD CD d ((D Ali a a so< - N O N O -n N 7 O - a 7 (o n 3 m z n o =r~ o C1 O C1 (o_ N a m N CD C CL O H (n O A J Cll 7 7 O fU T = 0 O S N 4 O CL 7 X CL O CL N CL 0 Cp O O n =r CT A CD DO w Go 0 C) ti Cho O L ~ Ib ti I Parcel 022-1006-80-105 11/12/2004 08:16 AM PAGE 1 OF 1 Alt. Parcel M 03.28.18.45B-10 022 - TOWN OF KINNICKINNIC Current XI ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 00 0 Tax Address: Owner(s): = Current Owner * AESCHLIMAN, RITA RITA AESCHLIMAN I 1283 CTY RD N ROBERTS WI 54023 I Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description * 1283 CTY RD N SC 4893 SCH D OF RIVER FALLS SP 0100 CHIP VALLEY VOTECH a Legal Description: Acres: 2.880 Plat: 0416-CSM 09/2670 SEC 3 T28N R18W PT NE SE BEING LOT 1 OF Block/Condo Bldg: LOT 1 CSM 9/2670 EXC PT TO ST CROIX CTY HWY Tract(s): (Sec-Twn-Rng 401/4 1601/4) 03-28N-18W NE SE Notes: W64 Parcel History: Date Doc # Vol/Page Type 08/19/2002 687456 1952/188 WD 04/27/2001 643838 1626/398 WD 2004 SUMMARY Bill M Fair Market Value: Assessed with: 130,100 Valuations: Last Changed: 06/11/2003 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.880 24,000 86,500 110,500 NO Totals for 2004: General Property 2.880 24,000 86,500 110,500 Woodland 0.000 0 0 Totals for 2003: General Property 2.880 24,000 86,500 110,500 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel 022-1006-80-100 11/23/2004 12:22 PM PAGE 1 OF 1 Alt. Parcel 03.28.18.456 022 - TOWN OF KINNICKINNIC Current , ] ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 00 2 Tax Address: Owner(s): Current Owner `AESCHLIMAN, RETIRED RETIRED AESCHLIMAN Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description * 1283 CTY RD N SC 4893 SCH D OF RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 3.910 Plat: N/A-NOT AVAILABLE SEC 3 T28N R18W PT NE SE BEING LOT 1 OF Block/Condo Bldg: CSM 9/2670 3.910 ACRES Tract(s): (Sec-Twn-Rng 401/4 1601/4) 03-28N-18W Notes: Parcel History: Date Doc # Vol/Page Type 04/27/2001 643838 1626/398 WD 11/03/2000 633015 1556/339 WD 07/23/1997 1054/559 WD 2004 SUMMARY This parcel will not get taxed. It exists soley Assessed with: for parcel history tracking purposes. Valuations: Last Changed: 08/28/2002 Description Class Acres Land Improve Total State Reason Totals for 2004: General Property 0.000 0 0 0 Woodland 0.000 0 0 Totals for 2003: General Property 0.000 0 0 0 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 112 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel 022-1006-80-105 10/03/2006 01:16 PM PAGE 1 OF 1 Alt. Parcel 03.28.18.45B-10 022 - TOWN OF KINNICKINNIC Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner RITA AESCHLIMAN O - AESCHLIMAN, RITA 1283 CTY RD N ROBERTS WI 54023 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 1283 CTY RD N SC 4893 RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 2.880 Plat: 2670-CSM 09/2670 SEC 3 T28N R18W PT NE SE BEING LOT 1 OF Block/Condo Bldg: LOT 1 CSM 9/2670 EXC PT TO ST CROIX CTY HWY Tract(s): (Sec-Twn-Rng 401/4 1601/4) 03-28N-18W NE SE Notes: Parcel History: 1-24-06 REQUEST FOR DEED TO CHG NAME Date Doc # Vol/Page Type SENT.JK 08/19/2002 687456 1952/188 WD 04/27/2001 643838 1626/398 WD 2006 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 08/10/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.880 50,000 126,000 176,000 NO Totals for 2006: General Property 2.880 50,000 126,000 176,000 Woodland 0.000 0 0 Totals for 2005: General Property 2.880 50,000 126,000 176,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: 10/13/2005 Batch 05-31 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 NNICKINNIC 28 N. R. 18 W. 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C'. c.9 Ch ~ Bo , Q 4 y 4' f 9 u. e ^ Th Loom a Marion € Fronk fl FOPa/ /°er n W r V O ~Sfa7r/e r. Bo ° cT FJ ~f v C risfiari - 0 o W C ~ ,/~e/s oyi Ci11C 41 ~j we ~ o Lo,~owich Whi r Nwal N Fu//rr 0 8o son ~o h h ~ ~~a /36 .s `a.W h c7crry Lesf /2° ay ~ y 0 Lesfe bib o F(~ /ao G e a~..t9 G/bso ees9 ;/zs s7-r ~ 4, son cTocobsor7. V 7 an •40 Louis•j /f r/ QSCa/` 7s oes,E ar/e/ao C ,9do/ h /%a i7 ® ~t~ `oo f'h./%~Ps fuPPe7f C_7, fnsa pnsLe ° • 6s~ ~j we. • /LB n z kph Gordon ~o /¢o 767 65 173.37 /6a a F/o /7ar/F Vh°, J. C C7i ffe W i/iam S, h co • /aM~ /i/ir7 age Th pson 4p o~~y°, X30 370 Bo fii~sio~e 77 `C se 4771 r p N7YR8 K o.n l~Va t v fL. f%ya y u r eo. Fosfe 3~ yC7a r2. 720 ~i°. v Y"~/rf A dre T Ca 17;11 de// Prc%.. .nd Lac -``O a~ '7g +,`Cx'~ v~ ~ v-~Z{ Lzo , /ieoCore 6o ao. Yo"'a" to ao s~ . 7n.~' ise J J`'o er7 /is FA~ p `u A ~o/d L7 4 ~iea,r, J~ (5' Lr ix rd:s F7i~:n~ ~c.,y L 4V ~j wen y ~o UC) JCOS r~ DDi Lub:c/7 c7j d0 ~R e.G y raker 37R9f 7 ~e? L sKS. o i~ o % w ha dus v u//er F 70 B e /inn sus Lesf ic.C- Barr 91-~a. 8 C/ar race f/ernen n ~ ~s~~ ue Su/ha y Bo .n' C. •Pask er Pes.Far v 96.67 40 C O Eugene cha4 //a3e/ 1acEf :7 ~mmeff E Beff /yi/ Co 1//- 7z /97 ~ a /zo cTOh + 7p r Pes,FarGeor e .E H 7.s c~vve~son • 65S /•;o /z7 s~ fi7an on Y, we X77 zoo W ~7 4o F :o Pa / cTOhr, ~ ` C'udd ,Efa.bcr°c 79 Ferr:~ 8o John 40 4.0 4o • 73 O VC, Bo ',Dorotfi Eu e e S 9 den ud~ffj /sa y 27o Ed.. ~ tfi 9 S3 `I. Le'° and Trim l Lib ~jri ,E7uhr~ /Jis. Le /,e k! /,C m ia. Tfwrs_ ~ q B / f/a ~s 0.<. • ~La/e7- e Eme ~sor7 akken j Pc°c a.r~: 7Bo 77 Fa/is coots /a ~ M ~ ' Max • 9nfo~ l ~l• 37 ~y{co 3 •--74 r.: /99. .s' ^ /zo BO wat R. cfi- tl~ /zo ~y r11V LLS La v 4 ~L1eslie C .39 y ao : (T Luci/ rs o The ✓ z1f f M 7'au/.sore Q, ~ o ~ v o~ ~a~, as FMa~ ~ E/rrLer~er77on J ~ v~ ,~er Seq ecliace s7 ¢ ~ /78 3 h ~ uni ~ 4o a°n Narrr7ari Ne/soi7 9 ~e/y ~ n W i2/ /zo 13~ ©/972 ~k~a dM P P b/~,I c.~Rev-7974 PIERCE GOLINTY tS/ x C'-yWs. ' RIVER FALLS COURTESY OF JOURNAL RIVER FALLS SURPLUS CITY Printing - Publishing L UMBER CO. Advertising - Office Supplies CLOTHING - FOOTWEAR - FURNITURE PHONE: 425 2484 North Main Street WHOLESALE AND RETAIL River Falls, Wisconsin MOBILE FALLS HOMES WISCONSIN 54022 "The Panel People" RADIO SHACK 425-2563 PHONE: 235-0466 - MENOMONIE, WISCONSIN AS BUILT SANITARY SYSTEM REPORT OWNER Oil 4-dH`. Jkl~ 11 TOWNSHIPS ~ SEC . T _j, RRW ADDRES , ST. CROI COUNTY WISCONSIN. SUBDIVISI LOT LOT SIZE PLAN VIEW Distances & dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Cf L i I di, ate ozt-h.) AArmoroow SCAL : SEPTIC TANK(S) 0 MFGR. CONCRETE- -STEEL 0. o- rings on cover Depth PUMPING CHAMBER SIZE PUMP MFGR. MODEL NO. GALLONS Per Cycle _ TRENCHES NO. of wilt length area BED NO. of lines width 1 length/ area dept to top o pipe NUMBER OF EEPA E ITS outside diameter total pit area AGGREGATES PERK RATE AREA REQUIRED AREA AS BUILT Disclaimer: The inspection of this system by St. Croix County does not imply complete compliance with State Administrative Codes. There are other areas that it is not possible to inspect at this point of construction. St. Croix County assumes no liability for system operation. However, if failure is noted the County will make every effort to determine cause of failure. GREASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYTEM. ~ INSPECTOR DATED 3 -go o PLUMBER ON JOB LICENSE NUMBER .j ip g • AS BUILT SANITARY SYSTEM REPORT N~ER , TOWNSHIP SEC. T N, R W 0. ADDRESS , ST. CROIX COUNTY, WISCONSIN. -BDIVISION , LOT LOT SIZE ' PLAN VIEW -Distances & dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM i { i a i ' j a i i CTN TF hidica~e North; ArrM'7 }j ! SCALE OPTIC TANK(S) MFGR. CONCRETE STEEL NO. or rings on cover Depth DRY WELL JtNCHES NO. of width length area j no. of lines width length area depth to top of pipe aGREGATE >..V, RATE AREA REQUIRED AREA AS BUILT I,SCiaimer: The inspection of this system by St. Croix County does not imply complete .0pliance with State Administrative Codes. There are other areas that it is not possible ,o inspect at this point of construction. St. Croix County assumes no liability for ystem operation. However, if failure is noted the County will make every effort to ;jtermine cause of failure. ,{EASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM. `INSPECTOR DATED PLUttBER ON JOB LICENSE NUMBER REPORT ON INSPECTION OF SANITARY PERMIT (1) Name and Address of Permit Holder Person/Persons at Site (2 )Date of Inspection f1(~i ; ~/X L 'Ge lc 7ti., To 4J q,lch 10-2-3- i c,4lVw w,nn~G Name, ress, icense o. o ns a ing plumber Time of Inspection (3 )INSTALLATION CONS TS OF: [Z]Septic Tank ❑ Seepage Trench ❑ Dosing Chamber ❑ Seepage Pit © Seepage Bed ❑ Holding Tank ❑ Fill System (4)BENCHMARK: (Permanent reference Point) escri e: tx%,It~~I!_t,__. t-ouNprgT(or~ Elevation of vertical reference point: Slope at site: (5)MATERIAL AND DEPTH OF SEWER: if,tW_ £ o(, i 75"OKrP A7 V m,< (6)SEPTIC TANK: Manufacturer: F_ Liquid Capacity: Tank Inl et El evati on '%1 " Tank Outlet El ev : q) ' -7%'7 # ft to lot or property line: > S ' # ft to well '-'(7)DOSING TANK: Manufacturer: # of gallons: # of gallon pump set for a cycle gallons; total capactiy of distribution lines gallon; size of pump head; gallon per minute ; horsepower ; brand name of pump and model number Is the warning device installed? ❑ YES ❑ NO Wired? ❑ YES ❑ NO v(8) HOLDING TANK: Manufacturer o gallons construction depth to the cover ft; If septic tank is being used are baffles removed? ❑ YES ❑ N0; ft from residence; ft from well; ft from property line. Type of warning device Is the warning device installed? ❑ YES ❑ NO; Wired? ❑ YES ❑ NO; Locking device on cover? ❑ YES ❑ NO; Diameter of vent and material ; Distance from building to vent ✓(9) SEEPAGE PIT SIZE: # of pits; ft diameter; ft liquid depth; ft to residence; ft to well; ft to property line; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than seepage pit inlet pipe-elevation ft; bottom of seepage pit elevation ft. (10) SEEPAGE BED SIZE: 3o ft width; ~S ft length; tile depth.; 90 'l i.neal feet tile; 3(ft to residence; >t oo' ft to wel l ; S-7 ft to lot or property line; >,;sc) ft to ordinary high water mark of lake or stream; > z o ft to edge of slopes greater than-20% falling away toward lakes, water courses or drainage ditches Elevation of tank discharge line entering bed q/' 3" ft. 11 SEEPAGE TRENCH: Total length of seepage trench ft; width ft; tile depth ft; ft to well; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than 20% falling away toward lakes, water courses or drainage ditches; elevation of tank discharge line entering seepage trench ft (12) Has system been installed in area indicated on EH 115? ❑ YES ® NO (13) Has system been installed in floodway? ❑ YES © NO Floodplain? ❑ YES © NO DILHR-SBD-6095 N.05/80 41_ c Signature of Inspector: 1 REPORT OF INSPECTION - IN"DIVIDUAL SEWAGE SYSTEM S anIt' t.zn y P F n mli-,t97 State S e p,t,i. c cz,~F,-,'-7 NAME ~ Township St. Croix County LOca.t-ion n = Section Lo,t # Subd-i.vi,6 ion SIPTIC TANK gaZtons Numben o6 compan,tmen-t,6 i tanCe. 6nom: We.zf Buitding " 12% .scope H.ighwa.ten - PUMPING CHAMBER S4,ze gatton4.. Pump Manu6actune4 Modet Numben IiJLUtNt, ANK S4, zegaUons •.Numben o6 Compa4 ments +•b Pumpen.__- A. ahm Syexem tance. 44om: Wett Bu.itding 120 stope Highwaten ABSORPTION SITE tried Tnenen D-i,5xance Strom: Wett Bu-itding i2o .6tope Highwaten ABSORPTION SITE DIMENSIONS W.id-th o6 tne-nch Requ..(n.ed anea__ St r Lenqth o6 e F- ne_ 3s' {,t Depth oA rock betow ,tike ~ i.n. NumbeA o6 tine. Depth o6 rock ove.h- -tits) i ~n Totak Zeng.th o6 tines At Depth oS take betow grade 39 'n V .,5 Lance between Une.6 At Stope o6 -tneneh 'n. pen 100 At To-tak ab,6onption anea ioU At~ Type o6 Coven: Papers on b.th.aw 1'11 DIMENSIONS Numben o6 pits Gnavef around pits yes no Outeide diamelten - 6t Depth betow inte,t At Totat abhonption anea At A~tea kC(tU.l("Avd 4t INS411,CTI-D hY TITLE APPROVED DATE 198 I:C JI- C T E V DATE 19 8 REASON FOR REJECTION EH 115 Rev. 9/78 REPORT ON SOIL BORINGS AND PERCOLATION TESTS WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES P.O. BOX 309, MADISON, WISCONSIN 53701 9 LOCATION: ~'/4,fir= '/4, Section T- 'N,Rb E-(rni W, Township or_Aua ~a+~ty Lot No. , Block No. County' l X, SEP 2 1,,I f, Subdivision Name ~ ZONl~t6 . _ Owner s/Bwyer:s-Name: d~ OFFICE ~n -I&, ?[n-TS bu / - d Mailing Address: TYPE OF OCCUPANCY: Residence - No. of Bedrooms Z COMMERCIAL J EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS 3 j 7_j)80 PERCOLATION TESTS S ~ zZ/~c SOIL MAP SHEET_ NAME OF SOIL MAP UNIT..~~~ PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM- SINCE HOLE HOLE AFTE INTERVAL BER INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN P- Z I-1 Z c G 7-S Q, P- P- SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, MOTTLING AND DEPTH TO BEDROCK NUMBER INCHES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES B- i0Z t~C,/-"j~ -7 ti-Z lb 3n sc,) 5 3.jo 5 1 S/ B- -ZC Qn S I S ~Z a In B- f`.~A.; > -7,6 •©V,. nsiI -'IL/' iBp sil jL; &.q c<I U; i3hSl B- 13. 1s & (S:i^ ZED ' Y an s I?> B- 4 r_ CAJG '7 -N Dk vrs I i3 l'1~ • 3n S'i t b'n sr_-1 y ` 3, S)qy~ B-- K 'G3 •r `E S L) PLAN V IEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy 630 Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. o ITCH - 3- f IBM - m o - SOT'Tum OF _ < r3~ 95 4-4. ij i 4 1 e +l•1'11' L _ e o ~ E n,_ I~3 gyp I P. I E V) f ® I ;T bAcsTe~$ol LPG I D l vERS 11~~'►IJ ` f cJltfL(: 'TLS _ ~}ouSt q i SEG. -Z.16_)4& SLStZFhC+E Ss,?pl,a S ~O ` E . PFN i~ -16 h)Cl lye i S~/ V9 F=o~~-StiTG_ DC r'tl ~.i 0:16 1 NX)TE Ira So ~3`~ 1'1 WSl" C'1N1i ls'CJ~' I LI:. _ I i <c'^Le %M=q0 ` I, the undersigend, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my knowledge and belief. Y C~ ~lZ X12 Certification No. S)~ 61 ` n-i & L Narrie (print) A.r'dress~.: i L~ Z LL~f~t1[~l 1 }~l l~C/J . ~S/t~i l - Name of installer if known Copy A - Local Authority CST Signature State and County State Permit # PLB 67 l~ Permit Application County Permi # for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: Gbeils 4j,'C-, B. LOCATION: Sjff '/4, Section T - N, R l E (or) J Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township ',V n i ICI /)ll i C' f~ C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance Single family- Duplex No. of Bedrooms No. of Persons D. SEPTIC TANK CAPACITY _4C"t,C1 Total gallons No. of tanks HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concretey Poured-in-Place Steel Fiberglass Other (specify) New Installation Replacement e< Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area Z'2 C -sq. ft. New Replacement Alternate (Specify) Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches Seepage Bed: Length Width 0,f Depth -16 it Tile depth (top) No. of Lines Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits Percent slope of land- 5;~ £ Distance from critical slope WATER SUPPLY: Private Joint ❑ Community ❑ Municipal ❑ Owners name as listed on EH 115 if other than present owner: I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the Cer ified . Soil Tester,J / NAME h (d1~c', C.S.T. #(G' and other information obtained from e e (owner/builder). y _ Plumber's Signature L. ~ Mf/MPRSW# Phone Plumber's Address r , 1 PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. , , , z , j J1- E , 4 f . I , r 3 . 7 i 3 . _ m. _ ,.m-. a. ..P F Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY Date of Application / JO Fees Paid: State v`~, County Date Permit Issued/Re?ectr& (date) Q -Issuing Agent Name Inspection Yes No State Valid# Date Recd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 7/1/78 ~ s rr C, rt d 42IZX3~ R ~N C Pre se ftY 'y 1 y ~`{ttnt~ ~ Tcl Yv: p r k. O t p ~ ' ~ ~Y e.d lI 1 v }'a {...:w~: 7_~xq.,, ueny~•.. G. 'r i 5 Z 8 i y 1 t; ; r , . ) k G ' i ! . a I t i ,v r T'.x JI.." t . fit. ~ r s.