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HomeMy WebLinkAbout020-1260-30-000 C c CD ° ~o p ° y M 0. O C o I N I V I 'n I oy, h ~ I I ~ I Z LL c 0 a I 3 ~ (D z u E rn U) :o d o I' z a m r N > N 1- z 0 c z v o Z d' m Z C o I co H c o m 'D 0) .N CL ~ I co c: C C Q U O o Q w O Z I- Z o N Q z ~ w ~C I y N E N Z\!l (0 N 10 J h O j G w r co C (O Q CL N M (n (A E w o r- 2 N n O 0 0 0 0 z° • w a a a IL o ca U) ~V co J L) rn rn Ali -c 0 r- N Q Z) N C1 (m m y O In m N Lo Ai O O O -x N C O O° C C j v 0) d `n 3 i aa)i c O v Of co O f6 Y E C L (°O ~ d C N O C co L W N O L 2~ - r Z' ~ r to H N V N N a) r- • N =5 a>i ca N m E c~ O N = J O Cn E cl E d c a w • R a o, m y c E u c A 0 a O in 0 a FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER )C TOWNSHIP ACS- GkIti SECTION T a CZ N-R / W ADDRESS49.;? ? T~S~ k; ST. CROIX COUNTY, WISCONSIN Ydl SUBDIVISION LOT LOT SIZE,&F/2d? ,5 PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM i 5 r ` INDICATE NORTH ARROW BENCHMARK:Elevation and description:-1~42Z 5'k) aL1k) Alternate benchmark SEPTIC TANK: Manuf acturer d f~ S Liquid Cap. 1 2 Rings used: Manhole cover elev:fBD 5 Final grade elev:_Gop Tank inlet elev.: Tank outlet elev.: 8 6 ° No. of feet from nearest road:Frontz-17, Side , Rear Ft. From nearest prop. line:Front-/S?-/,Side , Rear Ft. No. of feet from: Well k2Zd , Building: (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE ' a II PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: _Pump/Sigh Manufact.: Pump Size Elevation of inlet: Bottom of tank elevation Pump on elev.: Pu off elev.:_Gallons/cycle: Alarm: Man.: Switch Type: Location Distance fro earest prop. line: Front, Side, Rear„_Ft._ Distanc from: Well Building SOIL ABSORPTION SYSTEM Bed: Trench: c~ Seepage Pit: Width: _Length_. ~ Number of Lines: Z Area Built 900 cz~ Exist. Grade Elev. f On ~ Proposed Final Grade Elev. Fill depth to top of pipe: Z i No. feet from nearest prop. line:Front , Side , Rear,/ No. feet from well.)A_No. feet from building- &O HOLDING TANK Manufacturer: Capacity: No. of rings used: El ation of bottom tank: Elevation of inlet: No. feet from nea st prop. line:Front , Side , Rear Ft. No. feet from* Well, building-, nearest road Alarm Man acturer: INSPECTOR: DATE : PLUMBER ON JOB LICENSE NUMBER:. I 992Z2~? V 6/90:cj ' L Q a t Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM Cnunty: +,y and Human Relations Labor and Safety and Buildings Division INSPECTION REPORT Lot 17 St. Croix (ATTACH TO PERMIT) Prairie Vi ta ry Permit No.: GENERAL INFORMATION SE, SE, Sec. 21 , T29-Rl 9, stagecoach Tr. 1 149244 Permit Holder's Name: ❑ City ❑ Village T] Town of: State Plan ID No.: Patrick Leverty Hudson CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: L020-1260-30 TANK INFORMATION ELEVATION DATA a// 3TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Q CoAQ Benchmark ,4 b~ 446 (1 09 Aeration Bldg. Sewer [Holding St/ Ht Inlet 12.4 (o TANK SETBACK INFORMATION St/ Ht Outlet 5 Vent TANK TO P/ L WELL BLDG. Air Ito ntake ROAD Dt Inlet Septic NA D+-Be4-efn W. z NA Header f~+i.. I ' . 87 Aeration NA Dist. Pipe 83~ -77 Holding Bot. System r PUMP/ SIPHON INFORMATION Final Grade p Manufacturer Demand Model Number GPM TDH Lift Friction System I Loss mead Ft Forcemain Length Dia. Dist. Towels F_ _T SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS S 80 Z DIMEN I N SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING facturer. SETBACK INFORMATION Type m ,vnLF CHAMB S System: t~/Gflca, OR UNIT ER Model Number: DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length -f= Dia. ~F- Length ~ , Dia. Spacing -1-2-- 2_ SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Ale, P~2 Plan revision required? ❑ Yes No Use other side for additional information. P/ 19 SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. s DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY °...,..,.~.,e. St. Croix STATE SANvITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ` / 7 8% x 11 inches in size. ❑ Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. AOPEBTY OWNER PROPERTY LOCATION /J SE Y4 SE '/4, S 21 T 29 , N, R 19 xg (or) W PR ERTY OWNERS MAILI G ADDRESS LOT # BLOCK # 61 t-:), "a 17 n/a TY, ST TE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER SS-I-Zg Prarie Vista II. TYPE OF BUILDING: (Check one) ❑ State Owned E3 VILLLLAGE : NEAREST ROAD Hudson Stagecoach trl. ❑ Public El 1 or 2 Fam. Dwelling of bedrooms AR L Ax N MB ( ) 111. BUILDING USE: (If building type is public, check all that apply) _ a Co 0 - 30 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. 0 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION 600 780 780 .77 <3 96.98 Feet 100.48 Feet VII. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holding Tank x 1200 1 Weeks C . P . FX1 [I F1 Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installati f the onsite sews, a system shown on the attached plans. Plumber's Name (Print): Plumber's Si re: (No Sta RIO No.: Business Phone Number: Gary L. Steel !y ~ ( 3254 715 246-6200 Plumber's Address (Street, City, State, Zip C de) 54017 IX. COUNTY/DEPARTMENT USE ONLY Disapproved Sa itaryPermit Fee (Includes Groundwater a sue Issuing Agent Si nature (No Stamps) Approved El Owner Given Initial f Adverse Determination / - X. Surcharge Fee) X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber STC-100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor,(spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of property nc and SW 1/4 of SE 1/4 Location of property__UIL1/4 SE 1/4, Section 21 , T 29 N-R 19 W Township Hudson, St. Croix County, Wisconsin Mailing address 1150 East Seventh Street St. Paul, Minnesota 55106 Phone: 776-7423 Address of site 571 Stage Coach Trail subdivision name Prarie Vista 2nd Addition Lot no. 17 Other homes on property? ves XX No Previous owner of property Verlyn E. and Catherine A. Benny Total size of parcel 2.606 acres Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes XXNo Volume and Page Number as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER & THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the county Register of Deeds as Document No. , and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of County Register of deeds as Document No. 'Su f applicant Co-applicant MontaRari Homes, Ipc. - President November 12, 1991 Date of Signature Date of Signature Rf ~R rye; kr :a .v Y: ~ - 41 sill, Txic ' tion to the Town ,oil :r. $*Ogg. loaq i*" in lit f „x Viwin, Y }4••~ - _ .7 25' 3 k _y44 6t`j - e:. ~r a a r' 'i.• r ,fir ( tF i*ts ^ s w 7 e,~f tad / lot sit OftUnLm .,7,1~t tfiVF,~ , •l'Ci~~t' ~•`~uritYr. 41, ► . ft"T ,.tc, d., +q~ HYit~4~wosr' t~ k+T4!~+!Mt. kart shaA curt 1Na. f `R 77 +t d on thAs property ' p ti ~r r i t S. - t ~ 7• 3a w 4 < ~ i Wi-ssek!ft Sao* l ~ ' P Arid Aus 77, ~lMJt tarA'! '}t{' see s a .w.NIM~..Ji.»...» SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER MmTtnTr- s, Inc. ADDRESS: 571 Stage Coach Trail FIRE NO: an or 1/4 LOCATION: NW 1/4, SE 1/4, SEC. 21 T 29 N-R 19 W, TOWN OF: Hudson ST. CROIX COUNTY SUBDIVISION: Prarie Vista 2nd Addition LOT NO. 17 Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system: St. Croix County residents may be eligible to receive a grant to help with the cost of the replacement of a failing system, which was in operation prior to July 1, 1978. St Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to the. St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification from will be sent approximately 30 days prior to three year expiration. I/WE, the undersigned have read the above requirements and agree to maintain the private sewage disposal system-in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification form must be complete and returned to the St. Croix County Zoning officer within Q days of the three year expiration date. S I G N E Mo ahari Homes, Inc. - Vice President DATE: November 12, 1991 St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 pzf DEPARTMENT O REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS 'INDUSTRY, ~ . DIVISION P.O. BOX 76 LABOR AND- PERCOLATION TESTS (115) MADISO N WI 3707 HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNSHIPCITY: LOT NO.: BLK. NO.: SUBDIVISION NAME: SE 1/4 SE 1/4 21 129 NCR 19Por) W Hudson 17 n a Prarie Vista COUNTY: GMVX11 S BUYER'S NAME: MAILING ADDRESS: St. Croix Patrick Leverty 16827 7th. St. N., Oakdale, Din. 55128 USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PRO DESCRIPTIONS: PERCOLATION TESTS: Residence 3 n/a ~vew ❑Replace 10-8-91 10-8-91 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: MIS TEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM:(optional) 0 S ❑U E S ❑U 0 S ❑U ❑x U ❑ S EU conventional If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: n/a I Floodplain, indicate Floodplain elevation: n/a decimal' PROFILE DESCRIPTIONS Page 58 BxC2 BORING TOTAL DEPTH T GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH ELEVATION OBSERVED ES GHE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B-1 7.17 100.48 none >7.17 .67bl.1. 1.50bn.sil. .67bn.l.s. 4.33bn.c.s. B-2 7.17 100.18 none >7.17 .67bl.1. 1.33bn.sil. .50bn.l.s. 4.67bn.c.s. B 3 7.67 100.86 none >7.67 1.00bl.l. 1.67bn.sil. .50bn.l.s. 4.50bn.c.s. B 4 7.08 101.04 none >7.08 .67bl.1. 1.58bn.sil. .58bn.l.s. 4.25bn.c.s. B-5 7.42 101.28 none >7.42 .75bl.1. 1.75bn.sil. .42bn.l.s. 4.50bn.c.s. B- decimal' PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES -FERLQ NUMBER ]NHS AFTERSWELLING INTERVAL-MIN. I t D PER INCH P-1 3.50 none 3 6 6 6 <3 p-2 3.20 none 3 6 6 < P_ 3.88 none 6 6 6 <3 P- P P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION 96.98 a~ ! a, ~z to 1 t i F ~ t 11 B . _ N I t 1,S_ C, Z I f i,k D 1 ito I, the undersigned, 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 the location of the tests are correct to the best of my knowledge and belief. NAME (print : TESTS WERE COMPLETED ON: Gary L. Steel 10-8-91 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): 1554 200th. AVe., New Richmond, wi. 54017 2298 715-A6-6200 CST Sl /17 DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR•SBD-6395 (R. 10/83) - OVER - GUARANTEE In consideration of the Addendum to the Land Contract entered into between Verlyn and Catherine Benoy and Patrick and Marilyn s Leverty, on the terms and conditions thereof, the undersign guarantees the prompt payment of the Land Contract at a date *et-eAO vT early then January 31, 1992, and in accordance with all the terms and conditions of the original Land Contract and the Addendum, and agrees to all the terms and conditions of those documents and affirms the waivers and contents contained therein. The liability of the undersigned to enter into this guarantee shall be direct and not conditional or contingent on the pursuit of any 'remedies against either the Benoys or the Levertys or against they real estate at issue here and more particularly described as follows: Lot 17, Prairie Vista Second Addition to the Town of Hudson, St. Croix County, Wisconsin. Notice of acceptance is hereby waived. This shall be a continuing guarantee, extended to any notes given in extension or renewal of this Land Contract, notwithstanding that the original Land Contract may have been surrendered provided the liability of the undersigned shall not be increased over the amount contained in the original Land Contract as of the date this guarantee is signed, plus accrued and unpaid interest. Dated at St. Paul , Minnesota , this _1day of November, 1991. Montana x~ omen, Inc. ar o anar ras en y`i1?✓91 16 s l6 WALL & M i l LEt2 I ~►DDft tJM '~+D ki C OUTPUT veryxn S noy and Catherine BenpY and patriok and Marilyn Laverty, the, patties to a land controot filed with the Bt. Croix County Regiatar of Doods Office as Cco• No. 471122t and describing the following real estata►t Lat 7.y, Prairie Vista seoon4 Addition to the Town of Hudson, Oo Crolx -Caunty# hereby make this Addendum for good and valuable Gon#iftration. The land contract shad be amended to provide that building construction may be aormonoed on tha property befQtre the payment of the oohtroot is We in fNll under the following cotditionst %a That the payment of the land oontraot in full is guaze►mtead by Montanari Komar, Inc, by the pr#oideot of the corporation jUrt Montahari, to pay the full purchass price no later than aanuary 3t, 19929 2s Conbtruat ton opt a hone on the property nay- comraor e►e imzadiataly, as long as the ihatallmsht poymaht• are current and closing taken place no later than Ja=ory 31, 1903. 3, This Addendum in no way affoota the sellerls forealooure - and lien rights as set forth in the original Land Contract, This Addendum is ahtored into for the purpose of allowing the buyers, patldcR And Marilyn Leverty, to c+orilpl+ate Construation of housing on the property by January 31, 19021 It is rmrther intohdsd that the Levertys shall advance to the Benoys in Whange for a warranty deed, the Cull payment for the Lend Contract at the closing on the house to ba constructed by MQntanari Hone, lnot . Dated this ,.,.day of November, 19511 a r c Y er yn E. ~Anoy a~ ns . en0y ax ► ~X Y 91 STEEL'S SOIL SERVICE Gary L. Steel 988 N. Shore Drive C.S.T. 2298 New Richmond, WI 54017 MPRSW-3254 (715) 246-6200 t ~ & ►4 a (2 T►- ~~8~. to Sa 'No w _ h&~ i i i 166 N -a VY, l IN . 2 d` ~5 0 ,sot 5v + DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDi7STR1(, P.O. BOX 71 69 LABOR AND PERCOLATION TESTS (115) MADISON, WI 53707 HUMAN RELATIONS (ILHR 83.0911) & Chapter 145) LOCATION: SECTION: TOWNSHI ITY: LOT NO.: BLK. NO.: SUBDIVISION NAME: SE 1/4 SE 1/4 21 /729 N/R 19;~or) W Hudson 17 n a Prarie Vista COUNTY: 5ftVNWS/BUYER'S NAME: MAILING ADDRESS: St. Croix Patrick Leverty 6827 7th. St. N., Oakdale, 11n. 55128 DATES OBSERVATIONS MADE USE PROF I LE DS: PER OLATION TESTS: 1)0 - NO,BEDRMS.: COMMERCIALDESCRIPTION: ~lew ❑Replace 3 n/a 10-8-91 10-8-91 Residence J RATING: S= Site suitable for system U= Site unsuitable for system OMMENDED SYSTEM:(optional) ONVENTIONAL: MOUND: UIS PRESSURTEFIL Dnrconventional ES ❑U ~ S ❑U ❑U El S EZ U El S EIf Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under s. I Floodplain indicate Floodplain elevation:) n/a LHR 83.0915)Ib), indicate: n/a decimal' PROFILE DESCRIPTIONS page 58 BxC~ BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, OLOR, TEXTURE, AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. O BACK.) B-1 7.17 100.48 none >7.17 .67bl.1. 1.50bn.sil. .67bn.1'.S. 4.33bn.c.s. B 2 7.17 100.18 none >7.17 .67bl.1. 1.33bn.sil. .50bn.li.s. 4.67bn.c.s. B 3 7.67 100.86 none >7.67 1.00bl.l. 1.67bn.sil. .50bn.l.s. 4.50bn.c.s. 4 7.08 101.04 none >7.08 .67bl.1. 1.58bn.sil. .58bn.lli.s. 4.25bn.c.s. B B-5 7.42 101.28 none >7.42 .75bl.1. 1.75bn.sil. .42bn.l.s. 4.50bn.c.s. B- decimal' PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATER INCH ES NUMBER MEMES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERI6OD 2 PE 6 <3 P-1 3.50 none 3 6 6 6 < p- 2 3.20 none 3 6 P- 3 . SO 8 none 3 6 6 <3 P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or gist orta ibe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at al ri n t ion and percent of land slope. JJ SYSTEM ELEVATION 96.98 F e E e . F E ' f e J L 1. 80 Lbo- ,ko 3 e _ T_ T E~ E o t ti - - f ~ ~4 _ I 71, T -T IS6 _ 07 e I, the undersigned, 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 the location of the tests are correct to the best of my knowledge and belif. NAME (print : TESTS WERE COMPLI TED ON: Gary L. Steel 10-8-91 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): 1554 200th. AVe., New Richmond, wi. 54017 2298 715-,9146-6200 CST SI J DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER -