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HomeMy WebLinkAbout020-1118-80-000 3 0 N ~ i ~ ~ I m 0o a ~ I o d^ N ~ N O X O CV ti c r O L C! fV 3 0 CD N L pm E L as E c z m rn 3 0 ELO yv I Q m 3 M Z U) _ o Z w a m cjz 0 o z v rn iH Z r c c E ~ U M N 0. O O d y O L O i C 0 (0 O N C U Z co D tq E Z o c f0 O co E N Y ~p d 2 a to Y C m H m ~ O E co G Fra,.... a U Z F- N p - O con S O O O O ~ =aaa °o I 0 U) tn -jU S rnrn } O 0 N O N Y p N O m o o E C,4_ s co N c M N n m Q } (n L 7 r~+ N C D O C~ ° C O 3 O d 0 0 m 0 O O Q U C. O O O C C L p C C N mar/ U L I~ O I~ O N N d -O w C O N '9 d O F' N C-4 co :3 C) _ > N O c E U O Z - (n v~ d m € CL ~#t a I L: a~ rr`I~V +cl+ a c°'i c c E (D Parcel 020-1118-80-000 01/24/2005 08:12 AM ' PAGE 1 OF 1 Alt. Parcel 17.29.19.505 020 - TOWN OF HUDSON Current X', ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): Current Owner * WALDSCHMIDT, RICHARD L & MARGARET A RICHARD L & MARGARET A WALDSCHMIDT 367 BROOKWOOD DR HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description ` 367 BROOKWOOD DR SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 3.360 Plat: 2553-TROUT BROOK WOODS ADDITION SEC 17 & 18 T29N R1 9W TROUT BROOK WOODS Block/Condo Bldg: LOT 2 ADDITION LOT 2 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 17-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 848/216 07/23/1997 771/158 2004 SUMMARY Bill Fair Market Value: Assessed with: 48593 550,700 Valuations: Last Changed: 10/26/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.360 43,300 382,700 426,000 NO Totals for 2004: General Property 3.360 43,300 382,700 426,000 Woodland 0.000 0 0 Totals for 2003: General Property 3.360 43,300 382,700 426,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 306 Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSMENT 27.00 Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 0.00 Form - 8 T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER G G, LJrI v~Sc~i ~ni~' TOWNSHIP SEC. ZE T N-R lr W -5 L SOS ADDRESS u, ST. CROIX COUNTY, WISCONSIN 3Co~ 61'D o W Cod d~~t 4-41 Gi C~ SUBDIVISION LOT ~L LOT SIZE . Zc~ I I ~f g D- o D w. t O PLAN VIEW Distances and dimensions to meet requirements of IL-HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM a N INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used c~~,hc Q j/ Elevation of vertical reference point: Q Od Proposed slope at site: n _ /7~, SEPTIC TANK: Manufacturer: f ~ Liquid Capacity: G Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road.: Front,O Side, Rear, feet Off' ..From nearest property line : ' Front,OSide 10Rear, 0 feet Number of feet from: well /Pee',h,^4' 'r:d,uilding: ;e (Include this information of the above plot plan)( 2 reference dimensions to septic tank) F - PUMP CHAMBER ' Manufacturer: h,,kLiquid Capacity: v Pump Model:C e r jV? Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturers Sc% tyv Alarm Switch Type: &1& Number of feet from nearest property line: Front, O Side, Rear, © Ft.l3"4~ Number of feet from well: 11, ' Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: X Trench: Width:_ Length: Number of Lines: c Area Built: lCY Fill depth to top of pipe: -t-'Fo " Number of feet from nearest property line: Front, O Side, O Rear,0 Pt./.Sa Number of feet from well: Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box 0 been used on any of the above soil absorbtion sytems2 (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job: License Number: ~ 3/84:mj y DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION M ISON WI 53707 ~ State Plan I.D. Number: NE 4 , S 4 , S eC . 18 , T29 -R19 DO El ALTERATIVE (If assigned) Town of Hudson Lo t2 ❑ Holding Tank El In-Ground Pressure Mound NAME OF PERMIT HOLDER: IRT. Trout Brook ADDRESS OF PERMIT HOLDER: INSPECTI N AT t L • Woods, Hudson WI SW 7 C~-L, -~Y C/ BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: C T REF. PT. V.: Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: 6A A) 1; hurnaker S Croix 128744 SEPTIC TANK/ '7 'r' at IK::, MANUFACTURER: LIQUID CAPACITY: TANK INLET EL TANK OUTLET ELEV. : WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: (r C(_-s'~~ YES ❑ NO ❑ YES NO ' ~I T1b BEDDING: VENT DIA.: VENfiMATL.: HIGH WATER UMBER OF ROAD: PROPERTY WELL: BUILDING: VENT F ESH C .U• C ALARM: FEET FROM LIN / ~1 AIR INLET: ❑ YES NO ❑ YES NO NEAREST L / DOSING CHAMBE S ` " l,. MANUFACTURER: BEDDIN : LIQUID CAPACITY: PUMP MODEL: PUMP/Sff44@ MA~7_ PIER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: {~,aluJe ❑ YES NO --7150 , q-7 -7n .P YES [ 01 NO YES El NO I/ ~ PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDI G: VENT TO FRESH GALLONS PER CYCLE: LINE; / AIR INLET: / ~S ti 3a (DIFFERENCE FEET PUMP ON AND OFF BETWEEN ❑ YES ❑ NO NEAREST -1111- ~ SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: p v~ or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN , /Q ! _9 ~C C PD the soil is dry enough to continue. 7 CONVENTIONAL SYSTEM: S N. = G.` WIDTH: L NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID BED/TRENCH TRENCHES: / M RIAL: PIT DIMENSIONS ! S~ r GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL:n NO. DISTR: . NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: : ABOVE COVER: ELEV. INLET: ELEV. EN PIPES LINE: AIR INLET- v C~ G FEET FROM ( I / ' c~ c~ NEAREST MOUND SYSTEM: h' " Mound site plowed perpendicular 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/ H OVER TR DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRE URIZED DISTRIBUTION SYSTEM: BE /TRENCH WIDTH: LENGTH: TNO.OF RENCHES: LATERAL SPACING: FMRAXZ.L DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: EA.: 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: COMMENT: FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST Cl) ccJe oI~ CCruy1%2~r.c. e.__ Re in county file for audit. Sketch System on SIGNA RE: TITLE: Reverse Side. SBD-6710 (R. 06/88) HR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code Coin STATE SANITARY PER # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ 8% X 11 inches in size. rf evi o to revious application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. na, PROPERTY OWNER PROPERTY LOCATION 22, P. 60 I%'/a %a, S 1jr T , N, R E (or),Wl ,41 PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # Odin: " dGi~,Sr Ae a.- 1r C STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER ed ❑ VILLAGE NE EST ROD II. TYPE OF BUILDING: (Check one) El State Own ❑ Public ~•-1 or 2 Fam. Dwelling- # of bedrooms AR EL TAX NUMBER(S) III. 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. TYPPEII OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. X1 New 2.E] Replacement 3. ❑ Replacement of 4.E] 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 54 ELEVATION REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) 6 5_0 1 4; 1/ sr All- I Feet OQ• 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 structed Septic Tank or Holdin Tank OUlJ Lift Pump Tank/Si hon Chamber / L✓Ga3t' El 1 1:1 0 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) MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): 4"S ~5_ ii -P IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuin Agent Signature (NO Stamps) 0 Approved ❑ Owner Given initial Surcharge Fee) Adverse Determination /yO 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 R INSTRUCTIONS 1 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 prior to installation. 5. Onsite sewage systems must be 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. Ill. 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) i 1 • 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 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 014-k Wo/c/ 6eJ~ mr'd Location of property IVC 1/4=1/4, Section T Township 1 V SO Mailing address Address of site <& 2 Laid ~f-wL I J004 Bubdlvlsion name r,"I Raw d s Lot number 2 Previous owner of property a~ IN. /°/D4 a! Total size of parcel Out- + Date parcel was created /!a y MY Are all corners and lot lines identifiable? es No Is this property being developed for resale (spec house)? es No Volume .'9q g and Page Number Z_ 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, and 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 (out) 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. qSb y S$• ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds, as Document No. LISSO LIS,9 i 81 natur of caner Signature of Co-Owner (If Applicable) / Date f Si nature Date of Signature C 3.1. lie • i. 'K Intl:.. .w.».»».« w....»».«...•......w.... "vwTw"".'w!•.... «.....w». y~ • sun wN All mum NIT r Vii....arr............»....»»......» ~~..+w. r sip t 4W Um domk%w& S&I Mimi ~ 1 1 STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER JI)1~4 14),q /./:s -h , l d L ROUTE/BOX NUMBER Lof Z Tour .9rooK L w6s FIRE NO. CITY/STATE Udsori I ZJi~. ZIP 5110/(0 PROPERTY LOCATION: NC114 SE 1/4, Section T 29 N, R__/y W, Town of dSOAJ , St. Croix County, Subdivision ;Ieov~ 9rcaK t oodS , Lot No. 2 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 for a MAXIMUM of $3000 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 SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to 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 form 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 Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. SIGNED > DATE St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386-4680 Sign, Date, and Return to above address I'i DFJ.PA}RTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS IWOU9TxY, DIVISION 7969 LABOR AND PERCOLATION TESTS (115) MAD P.O. ISONBOX 3707 HUMAN RELATIONS ` / , WI 53707 (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNSHIP 64W'W*t'1TY: LOT NO.:BLK. NO.: SUBDIVISION NAME: N~ 1/asp' 4 /9 /T79 Wig E (o >~s5 ~ 2 e r_,lr oGr COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: S-F C2~ r x , L~ t. ld c~w>y L of Trod- Ebro k 06 as USE DATES OBSERVATIONS MADE NO. BMS : COMMER IAL DESCRIPTION: PRO R TIONS: R A ION TESTS: Residence I EDR EDR r-------• XNew ❑Replace 1 q Q 4/9b -Sol RATING: S= Site suitable for system U= Site unsuitable for system rON\4ENTIONU JMOS. ❑U IN G X1`7 PEA RESSURE: ISYSTEM-1MS U N~FILLHO[LDSG T~ . R0aW /ND ED SYSTEM: /6rVA'„IoPtiopa^) If Percolation Tests are NOT required DESIGN RATE: If an portion of the tested area is in the Al under s. ILHR 83.09(5)(b), indcate; C<y1~ l I Floodplain, indicate Floodplain elevation: &C PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH", ELEVATION OBSERVED EST. IGHES TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 1.~2 Zoo" A3 ONE 4'Z B- 7.9'7 149,8 i4 [_F ? 7,9Z. 1►"13CSLTS 3C"190,,, tM.S $„L T $0tv ►~'i~ yy++ a may- (,yt - M B d ~az 9.97ai > .4Z " Qc . .r S .s s~ r ; G,a B- 4" eat, 111-5 1* Crele B- G 9z ~U o ►~o > `>,9Z 7o LSLrs "8~rtr't c~~ D>LC r} PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER IfS AFTERSWELLING INTERVAL-MIN. P RI D 1 P RIOD2 PERIOD PER INCH P •4b No NI• zoo 3,90 ' P- Z 6. C> r lows /99. I b P- - 3 3 o no~r~ - - < 3 P- P- L.LZVr,` iC d 1 r 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 sh~M their to ation on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. Ct~a.- ~gop~n A~ < pt ~e Irv z7f k: SYSTEM ELEVATMI: ~ <v = od' QLTL~N fi w T I - 7 Q t N NOTE- I:N62t~ 0Z Z TL-JO SC-PA'?9TL, L` D UC, u _ _ i M 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: JAQYtY J6W ►.15aN Jbt4 sat; Su t--'/ I ca 4ue use Q /99tc) ADDRESS: ICERTIFICATIOP NUMBER: P ONE NU BER(optional): -4o sco,r C 7"~t1 `•;_1p.r E. ta~s~. ID ~ g 6U Q~CS~ CST S AnTnURE: •RIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. SBD-6395 (R. 10/83) - OVER - ' ~ ~ ~ n, ~'dT' ,v c= f~ S-~~ s~~ B' T~ 9 /~~.-.lsd*/ ' ~ , r2~~+~~`,c3,~~. c.~ !/ads a lap T S rc._. bd- k ~ i All S s9 ~n v h rr /2~ ~3S` 47