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` DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFET & BUILDING
LABOR & HUMAN RELATIONS DIVISION
F.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
MgKAD~SON, W~ 53707 State Plan I.D. Number:
iV LY y, L~lii4, eC. 16,T29 -R19 (If assigned)
Towon of Hudson, Lo t~-2 CONVENTIONAL ❑ ALTERATIVE
Sr I-I Holing Tank 1:1 In-Ground Pressure El Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
C Rd A Hudson WI 6/
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. LEV.: CST REF. PT. ELE a i
o~
ln~ 014- 4c, I (,-A n Er-
Name of Plumber: MP/MPRSW No : County: Sanitary Permit Number: Joseph A. Stangi 6921 St. Cxelx
28726
SEPTIC TANK D' o o f A Le C s /U Z 1G. 20~
MANUFACTURER: LIQUID CAPACITY: TANK INLET EL ANK OUTL WARNING LABEL LOCKING COVER
1
PROVIDED: PROVIDED:
/0(,, Z~ ~,1Z~ YES ❑NO ❑YES DC I NO
S G
BEDDING: T DIA. 4@141MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY 1\~ WELL: BUILDING: VENT TO FRESH
C, C D, ALARM: FEET FROM LINE: AIR INLET
❑ YES NO ❑ YES NO NEAREST /j
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
- PROVIDED: PROVIDED:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM AIR INLET:
PUMP ON AND OFF El YES [D NO NEAREST---*
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL A G:
or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTE <r ` 5 5 ELe d, = o o /
BED/TRENCH WIDTH: LERGTW NO. DISTR. PIPE SPACING: COVER INSIDEDIA.: #PITS: LIQUID
TRENCHES: MATERIAL:/ PIT DEPTH:
DIMENSIONS V T
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. IPE DISTR. PIPE MAT RIALH.NBELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END: IPES: FEET T LINE: AIR
INLET:
NEAREST 1111~ v ~s . 75 1 7 S
MOUND SYSTEM: f
Mound site plowed perpendicui-far to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW
❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED.
SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS;
❑ YES ❑ NO ❑ YES ❑ NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED:
CENTER: EDGES:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING:
ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.:
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO
INFORMATION APPROVED PLANS
❑ YES ❑ NO ❑ YES ❑ NO
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
COMMENTS: FEET FROM LINE:
❑ YES ❑ NO ❑ YES ❑ NO NEAREST
(C U-^ Cam"'' . 't r
L-
Sketch System on R ain in county file for audit.
Reverse Side. SIGNATU 4-1 7t~,~~ TITLE:
SBD-6710 (R. 06/88) /
701LHR SANITARY PERMIT APPLICATION COUNTY
In accord with ILHR 83.05, Wis. Adm. Code, C feo /
STATE SANITARY PERMIT #
-Attach complete plans (~l to the county copy only) for the system, on paper not less than f~
~~iopr~vious 8% x 11 inches in size. ❑ Cdecevisi n application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. IVZA-
PROPERTY OWNER PROPERTY LOCATION
VERAJE W OA) AJk11/4 S 1,6 T o1 N, R l E (or) W
PROPERTY OWNER'S M,/AILING ADD/DRESS LOT # BLOCK #
5-119 C7~ /T . PUP5.0 A / .
CITY, STATE lvol(e CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
HUD SatiJ Wt, 1(9/5- ,F6-
II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD
) ❑ State Owned ❑ VILLAGE ; pup S onJ s .lJl2 J /U F
lZ =NO ❑ Public N11 or 2 Fam. Dwelling- # of bedrooms 3 PARCEL TAX NUMBER(S)
111. BUILDING USE: (If building type is public, check all that apply)
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. 21 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection Of 5.0 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 0 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
V1. 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
/ b`~o4eet / o G. 7S-Feet
1_/ I S a . 7oZ 3 1A)
1 6 . 34
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 structed
Septic Tank or Holdin Tank W/E SRS (_OE
Lift Pump Tank/Siphon Chamber NIA
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number:
~bS~Pf~ 4, AJG-L Q. ^4 6 ?9-/
Plumber's Address (Street, City, State, Zip Cod
D 97 fgthof 4111e-E Cvtst~ S~oo~
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuin Agent Signature (No Stamps)
Approved F-1 Owner Given Initial Surcharge Feel
Adverse Determination ~ I P
X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety s Buildings Division, Owner, Plumber
INSTRUCTIONS i
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be
submitted to the county priortLinstalla
5. Onsite sewage systems mus a properly maintained. The septic tank(s) must be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the
State of Wisconsin, Safety & Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of
where the system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or
repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested in ##1-7.
VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of
tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all
septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received
experimental product approval from DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form.
IX. County/Department Use Only.
X. County/Department Use Only.
Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service;
streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system
areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by the county; E) soil test data on a 115 form; and F) all sizing information.
- - - - - - - - - - - -
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of
regulated practices which can effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater, ground-
water contamination investigations and establishment of standards.
SBD-6398 (R.11/88)
. APPLICATION FOR SANITARY PERMIT
STC-100
This application form is to be completed in full and signed by the owner(s) of
the property being developed. Any inadequacles will only result In delays of
the petmit issuance. Should this development be intended tot tesale by
sold second should
thls office retained
with the
completed ownst/contzectotelopec
property Is then a
apptopciate deed recording.
.Owner of property
Location of property 1/4/4. 8ectlon
Township
Malllnq address
Address of alto
•ubdlvlslon name
Lot number
Previous owner of property
Total size of parcel
Date patcal was created o --A, -2,
Ace all corners and lot lines identifiable? < on 0
is this coettY being developed foe resale (spec house)? as Mo
P P
Volume and Page Number t46 o as recorded with the Register of Deeds.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
INCLUDE WITH THIS APPLICATION Tits FOLLOWING:
A WARRANTY DEED which Includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER$ and
the REAL OF THE RE018TER OF D$EDS. In addition, a certified survey, if
4vallable, would be helpful so as to avoid delays of the reviewing process. If
the deed description references to a Cestlfled survey Map, the Cettitled Survey
Map shall also be required.
PROPERTY OWNER CERTIFICATION
t(Wa) certify that all statements on this form are true to the best of my (our)
knowledge; that I (we) am (ace) the owner(s) of the property described In
this Information [arm, by virtue of a warranty deed recorded In the Office of
the County Register of Deeds as Document No. ; and that t (We)
Presently own the proposed alto for the sewage disposal system (or I (we) have
obtained an easement, to tun with the above described property, tot the
construction of geld system, and the same has been duly recorded In the office
of 6 County Register of Deeds, as Document No 1.
Signature of owner 8101 Lute of co-owner (If Applicable)
C)•~-4 Z ~ t a
Dat of Signature Date o signature
JI
OARRANTY DEED (Former Statutory Form). ,8009TA PUn 61 Miller-Davis Co., Minneelrolie, Minn.
-Form No. 9-W.--_..
259581
is nbentttrje, Made by 8t. Croix County public Welfare Department
4i
.
grantor of y$ ~ '(~O1z County, Wisconsin, hereby convey and warrant to
Vernon. Waxppnand Irene Waxon„ husband and wife as joint
tenants "d, trot 11ran t?naat{ in common St Croix eea, o Cottnt✓
Wisconsin, for the suns, of One pollar and other good and valuable consideration
the following tract of Lana' int - St. Croix Coltnty, State of Trisconsin: ~
{ The West bts-i-half (J) of the Southeast Quarter (SS})
of 3eotion':..Sixteen 16), Township Twenty-nine (29),
North of Range Nineteen (19) West, excepting the
railroad right-of-way of the Chicago, ST. Paul,
Ninneapolts and Omaha Railway Company and excepting
a conveyance of lands to St. Croix County for highway
purposes as shown in Volume "336" Deeds, page 68 in
the office of the Register of Deeds for St. Croix
County, and subject to an easement to the Wisconsin
Telephone Company as shown in Volume 11298" Deeds,
page 371, in the office of the Register of Deeds
for St. Croix County.
REGISTERS OFFICE
ST, CROIX CO.. WIG.
i
_ Recd for Record this_3Qth-
day of_5_Rtem1Zer_A.D.19-59
y at_ :00----- A., M.
Reglste o~ I
*n 30itttrsa U14treaf,The said grantor ha0 hereunto set his hand anti scat thi-r
28th day of September .4. D. 19 69.
SIGNED AND SEALED IN PRESENCE OF
St. Cr x Count Publ ll~f'are~ Dept..
Kenneth H. Bayed' B SE.rL1
7 unner S. Briah Direcor__
Mikii Ellen Marlette
Mate of isronsitt,
. ss. •
i St. Croix County
Personally came before me, this 28th day of September
a. D. 19 59 , the above named St. Croix County Public Welfare Department
By Sumner S. Bright, Director
to me known to be the person . who executed the foregoing instrurnmt,A*wknozvledged the same.
This instrument drafted,by
Kenneth H. 8ayes,:Attorsey`; `
at Law, Hudson, Wisconsin.
d St q crq. A County, Iris. 1
Notary Public, j CIO My commission expires---, ~ - , .4. D. 19 60
i *Typewrite Name under each Signn~ure ' ~ i
w
• SEPTIC TANK MAINTENANCE AGREEMENT 0
St. Croix County P-A
OWNER/BUYER,
Fire Number o
ROUTE/BOX NUMBER ' ' - , d
CITY/ STATE ZIP S o r
PROPERTY LOCATION :'=k', S L k, Section, T.19 N, RW,
Town of St. Croix County,
Subdivision Lot number_ •
Improper use and maintenance of your septic o system maintenance could result in
con-
its premature failure to handle wastes.
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed''sept'ic tank pumper. What you put into
the system can affect t e unct on ot the septic.tank as a treat-
ment-stage in the waste disposal system. •
St. Croix Countyy residents-may be eligible to recieve a grant for
a maximum of 60% of the cost.of 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 'sys't'ems agree to keep their system properly
maintained.
The property owner agrees to submit to St.. Croix County Zoning a
certification form, signed by the owner and by a mater plumber,
journeyman plumber, restricted plumber or..a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and •(2)•after inspection and pumping (if nec-
essary), the septic-.tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year-expiration. y
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 Depart- w
went of Natural Resources. Certification form must be completed .d and returned
ix County Zoning Office within 30 days
to the St. Croix
of the three year expiration date. \
SIGNED `1 - W
DATE -
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
386-4680
Sign, date and return to the above address.
c-r';,
{~U~S~ W ~ s ~ , S'~'0~l0
N 0 k7t, R' Ll N E ST A-T°1 Old
-PROPERTY l-t N E
ESNC A MP r- G 1'/ Taw pipe LoT 2..
(+T NW Co Q OF i.oT,7
too
%361
o WELL
~p0o
{{yy ~hL ~ Ago
~V B'-r ~~t IOry mt
LEVAMW
04,00 gs, T ~R~ uE way
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44
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FILED
. s
OCT 031989o
JAMES O'CONNELL
Register of Dws
• L Cft Co., WI I
452056 w N
.CERTIFIED SURVEY MAP
Located in the NW 1 /4 of the SE 1 /4 of Section 16, Town of
Hudson, St. Croix County, Wisconsin, T29N, R19W
SURVEYED FOR, VERNON WAXON
549 CTY. TK. 'A
HUDSON, W1. 54016
Monumented Center of Section 16, also
the SW corner of the plat of North Line Monumented South line of
Station II, 1" iron pipe found. North Line Station II
EAST LINE OF THE NW 1/4
NORTHLINE STATION II I NORTH. LINE OF OF THE SEI/4
VOl. a 6 THE SEI/4
I ] g e .
E 1 /4 COR. S
I Lot 25 I 6 I Lot 26 SECTION 16
S 9' 56 '5 W I I T29N, R 19W
527.99'"E-' (S89;47-08"W
~ III
N 89 ° 56'57 400.00
LOT 2 le
ma W 220
W 93,97Z square feet a N 6~ 0 00
W . (2. 16 acres) 5 0A In1
W W in M zi
rn 9 Q)
v v
°o m 02 y ~ in W to LOT 1 iu ~
rn A60 02 a m N w
z 6ti y+W I ° 111,468 square too ~•I
al .p2~,• feet ° .4~
~I ti 5 6 A7~'•~" I I (2.56 acres)
o zl
W~ N a o► w
W LOT 3 Ns I h ~
~I
•
zI 123,291 square feet s•o0 wi 325.93 14'
~I In N 89'56'57"E
W n (2.83 acres) FENCE
n hr0 LINE
Nryry(yP UNPLATTED_LANDc N S Bearings
cn = referenced
311.95' to the
N 89'56'57'E monumented
North line
LEGEND of the SE
' 1/4
A$I- Section Corner Monument SCALE IN FEET 1"-- 150, Section 16,
assumed
P, 1.41" iron rebar found of 'r 51 150' 300' N8905615711E
0 l "X24" round iron pipe wieghing
1.68 lbs/ lin. ft. set.
( N89°4T'oe*Previously recorded information
NOTE; Theoretical Center of Section
is N58057.'40"W 12. 17' of Center of Curve 1 Curve 2
Section as found monumented. Nothing
set at theoretical Center of Section. Central angle 27028'VO" 27028'00"
Radius 30q.00' 366.001
Arc length 143.82' 175.45'
r•1 Chrd Brng S9°10'38"W S9°10'38"W
p' Chrd length 142.44' 173.78'
OCT 0 3 In"
CROU! ` This instrument drafted by;
~
A},pyy~;M~~;. "VOLUME 8 PAGE 2160
488-1455A
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
DIVISION
W.OIP3TRY;
I1,ABOR AND PERCOLATION TESTS (115) P.O. MADISON, WI BOX 7969
7969
r;UMAN RELATIONS 53707
(H63.08(1) !It Chapter 145.045)
SECTION: IQWNSHI UNICIPALITY: 0.' LK. NO.: S BDI IS NAME:
i a
NI 4 Y4 r 1/ /6 /Tzl N r 9 E (or. u &s o z. Ro t~os~ ~ CS M
COUNTY: E K'S A ADDRESS:
ST~.>Po?x. ~6Q Ax S~9`1- CTN "A" Nulusoti
USE DATES 00SERVATIONS M."sDE
isF~ia it r r~; c 1i='isi?J+ • PERCOLATION TE
eXResidence 7A)y ifNew ❑Replaa 41 b / S- A LG I $ 17zg
t~s k ayt~ S$ 5a)cs r3uRKN irr
RATING: S• Site suitable for systern U- Site unsuitable for system
OS~ M` ptionl)
V (~~~L: M 1, - ~+LL O 0 ❑ e7 cG T h: IREOMMENDENV&D
'Y
S hJa/ OU I ZS ❑OU. ISES, Y E.'f,
Pe
rcolation Tests are NOT required DESIGN RATE: [Floodplain, ny portion of the tested area is In the
der s.H63.09(5)(b), indicate: LASTS Indicate Floodplain elevation: AIA
PROFILE DESCRIPTIONS
60R NNG A ER-IN CHARACTER IL I THICKNESS. COLOR, TEXTURE, AND DEPTH
NUMBER pjMfg ELEVATION
il? EST TO BEDROCK F OBSERVED ISEE ABBRV. ON BACK.)
B. .2S 113-+.19 n/oIq ?9.z~ c" « z' o stc 3s B icstC~~c s~' T Q.,►~s
B. Z 9,75 64 .ZO > 9.7 S 7"LLTS rZ" S• 2~"8a CSdCa 6" T 19
B- Z /O$ ,6S No rod > . CC ! "$Q St L /5 ~ Rum le 14" ✓~S
B- d Ia,7S /06.9 NOrJ > L-M ?1~ R CS~t~s ~ b 9e LT 1Q r1'IS
B- /7 9A 'V i~ /0,1 rZ"BtL 21"B rjs•i: g~~t?rJCS{ y~
B-
D~ PERCOLATION TESTS
TEST WATERINHOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MNUTES
NUMBER PT 8 AFTERSWELLING INTERVAL-MIN. PERIOD I' PERIOD2 PERIOD 3 PER INCH
P. 3 .Z b 16-1.Z0 "k
P- 3 v /AZs $o > Z >
P- A T L
P- -
P-
PLOT PLAN: Show locations of percolation tests, ail borings and the dimensions of suitable soil areas, indicate sale or distances. Describe what are the hori-
tontal and venial 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- LQd Q 6 1 A I "IREaAP,
L ,
T
,
474_
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1
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ndersigned, 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
trative Coda, and that the date recorded and the location of the tests are correct to the best of my knowledge and belief.
int : TESTS WERE COMPLETED ON:
VEY C7. JauNSo'nl ll?OS 4 SLsAye x IV, INS- ALL /T /R%'9 CERTIFICATION NUMBER: PHONE N MBERloptionali
Stcol~h Sr ►-J U So YVI S4V► ~ ~'4 ~O'1Lv
ST SI N TUBE:
riginal and one copy to Local Authority, Property Owner and Soil Totter.
02/82) - OVER -