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FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER 2~2:/Oz'o-'o TOWNSHIP
SECTION T / N-R_C'_W
ADDRESS s-ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
I
1
l
n
J~1
INDICATE NORTH ARROW
BENCHMARK:Elevation and description: Pz,za' o
Alternate benchmark
SEPTIC TANK: Manufacturer: (n,„ X~ ~;_~Liquid cap.
Rings used: '"Manhole cover elev:Final grade elev:
Tank inlet elev.: L Tank outlet elev.:? 7
No. of feet from nearest road:FrontjL_, Side Rear Ft
Side Rear Ft.
From nearest prop. line:Front_ Zs"
No. of feet from: Well , Building: /
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufact.: Pump Size
Elevation of inlet: Bottom of tank elevation
Pump on elev.: Pump off elev.: Gallons/cycle:
Alarm: Man.: Switch Type: Location
Distance from nearest prop. line: Front_, Side_, Rear Ft.
Distance from: Well Building
SOIL ABSORPTION SYSTEM
Bed: Trench: Seepage Pit:
Width: '
f,2 Length_ Number of Lines:
Area Built ✓
Exist. Grade Elev. -2L2.72 -Proposed Final Grade Elev.
Fill depth to top of
P pipe: No. feet from nearest prop. line:Front Side Rear--Ft.//-S-6
No. feet from well: No. feet from building
HOLDING TANK
Manufacturer: Capacity:
No. of rings used: Elevation of bottom tank:
Elevation of inlet:
No. feet from nearest prop. line:Front , Side Rear Ft.
No. feet from: Well building , nearest road
Alarm Manufacturer:
INSPECTOR: /
DATE : PLUMBER ON JOB:
l/
LICENSE NUMBER:
6/90:cj
Aq J6025,0
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING
LABOR & Hk!MAN RELATIONS DIVISION
P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
MADIS N WI 3707 State Plan I.D. Number:
SE-,~1+ eC.3.T31-R19 CONVENTIONAL El ALTERATIVE (If assigned)
Town of Somerset
T wn R ❑ Hol ing Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Barrv Richardson 1408 Cedar Ave. 3 Somerset WI 0-0-76 c;,133
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. EL r
r _
o aus 4t,,.,, f I -S•/ /U3 4 O
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
Calvin Powers Jr. 1563 St. Croix 128864
SEPTIC TANK/ or d' vet': I ~ . G
MANUFACTURER: LIQUID CAPACITY: TANK INLET E TANK OU EV.: WARNING LABEL LOCKING COVER
Co
' PROVIDED: PROVIDED: AS,
8, 9; YES ❑ NO ❑ YES NO
BEDDING: vrw DIA.: 4&9 MATL.: HIGH WATE ✓ NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
C.O. If O, ALARM: FEET FROM LINE: O I AIR IN ET:
TLr
❑ YES NO ~ 4 1 _ ~ ❑ YES NO NEAREST---*
MANUFACTURER: BE DING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
GALLONS PER CYCLE: PUMP A NTROLS OPERATIONAL: NUEMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FET FROM LINE: AIR INLET:
PUMP ON AND OFF ❑ YES NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE 1-MATERIAL AND MARKING:
or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN
the soil is dry enough to continue.
CONVENTIONAL SYSTEM ,$3' c rr =
WIDTH: LEN NO.OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID
BED/TRENCH TRENCHES: MATERIAL
/ PIT
DIMENSIONS Z To 11 j (p 7-V " r"
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DIST PIP MATERIA NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
/ . AIR INLET:
BELOW PIPES: ABOVE COVER: ELEV. INLE : ELEV. END: / 4 /0(~[ 12 PIPES: LINE:
r/ 3 f rr 91 %N , 'i FEET FROM ! (I '
(i A- NEAREST
MOUND SYSTEM:
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/BE DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED:
CENTER: EDGES:
❑ YES ❑ NO ❑ YES ❑ 46 ❑ YES ❑ NO
PRESSURI D DISTRIBUTION SYSTEM:
BEDITRE H WIDTH: LENGTH: TRNO.OF ENCHES: LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FIL EPTH ABOVE COVER:
DIMENS NS
~R*t
MANIFOLD PUMP MANIFOLD DISTR. PIPE MA ,QLD MATERIAL: NO. DISTR. DISTR. DISTRIBUTION PIPE MATERIAL & MARKING:
Q1A-P
ELEV.: ELEV.: DIA.: ELEV.: -..,w PIPES:
ELE TION AND
DIS IBUTION 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
(2)& 04d /V,
in in county file for audit.
Sketch System on
Reverse Side. SIGN URE: TITLE:
SBD-6710 (R. 06/88)
01
P SANITARY PERMIT APPLICATION
!LHR In accord with ILHR 83.05, Wis. Adm. Code COUN-PI
j,STATE SANITARY PERMIT
-Attach complete plans (to the county copy only) for the system, on paper not less than El 8% x 11 inches in size. if id eon to previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
t/a '/a, S , N, R (or
PROPE TY NER'S MAILING ADDRESS LOT # BLOCK
CITY, STATE ZIP COD PHONE NUMBER SUBDIVISION NAME OR CSM UMBER
II. TYPE OF BUILDING: (Check one) CITY - NEAR ST ROAD
❑ State Owned VILLAGE
❑ Public [Z 1 or 2 Fam. Dwelling- # of bedrooms ~ PAR TAX N M R() Q~ 1 t06
III. BUILDING USE: (If building type is public, check all that apply) av 1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
30 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. ® 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 1-9 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. tt.) (Gals/ ay/sq. ft.) (Mi ./inch) ELEVATION
9-57 JO Feet 2 Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New lExisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Se tic Tank or Holdin Tank
Lift Pump Tank/Si hon Chamber El . [11 [71 1 F1
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsi sewage system shown on the attached plans.
Plumber's hi me (Print): Plu er's Signature (No am ) MP/MPRSW No.: Business Phone Number:
y N
Plumbe 's Address (Street, City, State, Zip C e .
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Sig rtflklp Stamps)
Surcharge Fee) J/I
X I Approved ❑ Owner Given Initial - Y
Adverse Determination
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
f
INSTRUCTIONS
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.
11. 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 ownetts) of
the property being developed. Any lnadequacIss will only result In delays of
the permit issuance. -Should this development be Intended got tesale by
owner/contractoc,(spee 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
Location of property y, 1/4 .x.+.1/4, section _ 3T.'...Y-1t-LL V
Township
Mailing address _ -114R ~t~,P . d"E
Address of site 4-
subdivision name„ A, •
Lot number
Previous owner of ptopecty ~~~~~-~-E~
Total size of parcel _ -3& .&1c .
Date patcal was created
Are 911 cornets and lot lines Identifiable? as 0
Is this property being developed toe resale tepee house)?as o
Volume SARIZI .and Page Number !5G 1 - as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING%
A WARRAXTY DIID which Includes a DOCUMINT NUMBIR, VOLUMR AND PAOt NUMane and
the 8EAL OF THE REGISTER OF DEEDS. In addltlon, a certified survey, if
available, would be helpful so as to avoid delays of the reviewing process. If
the deed description teterences to a Ceititled Survey Map, the Certified Survey
Map shall also be required.
PROPERTY OWNER CERTIFICATION
I(ve) cettlty that all statements on this form are true to the best of my (out)
Rnowledgel that I (we) am (ate) the owner(s) of the ptoperty described In
this Intotmetlon totm, by virtue of a werranty eed recorded In the Office of
the County Reglstet of Deeds as Document No. 'S~„ s~~/~• ) and that I (we)
ptesently own the proposed site lot the sewage disposal system (at I Iva) have
obtained an easement, to run with the above described ptopetty, tot the
consttuctlon of said "ystem, and the same has been duly recorded In the office
Of the County R glster of Deeds, as Document No. 1.
s gnat to of Owner signature of co-Owner tit Applicable)
Date of signature Date of signature
DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1988 THIS SPACE RESERVED FOR RECORDING DATA
WARRANTY DEED
V% WIPAGE561
_ 61.9 REGISTER'S OFFICE
ST. CROIX Co., WI
This Deed, made between Harold. J:__Schachtner_ and "
• Recd
joint___"____,____
Margaret ahtner,__ husband. a............. ifes for Record
texialats at 0 CT2 9 1990
. - , Grantor, 11:45 A. M
and"-----Harry- S.""Riahardaon-.and..8uaan..H,.."Ri cha> daQn,-.hushan /y1
and_wife as_survivorship marital
property----"-_"- v
ReglslerofDQ 4,
Grantee,
Witnesseth, That the said Grantor, for a valuable consideration. of
one..da1J ar.-and-_aiihar.-gaad..and"-xaluahla--nansidaxax~Qna_.-.. -
conveys to Grantee the following described real estate in -...._.-S:t._. CSO.i.$..-__-..
GUY T. LUDVIGSON,S.C.
County, State of Wisconsin: P. 0. Box 337
On-LA wl 54020
Part of the Southeast Quarter of the Southwest Quarter Tax Parcel No_
(SE4 of SWD of Section 3, T31N, R19W, described as
follows: Lot 1 of Certified Survey Map filed
September 27, 1989, in, Volume "8", page 2155, as
Document No,':45189;.,
. , TRANSFER
00
This deed is given in satisfaction of Land Contract between parites dated September 30
1989, recorded October 3, 1989, in Volume 852, page 548, as Document No. 452043.
is not
This homestead property.
(is) (ie not)'
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And------------ grantor.........................................
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
easements and restrictions of record and acts or omission of Purchaser/Grantee that
may have created liens or judgments against the parcel
and will warrant and defend the same.
Dated this 19th October 19.90-"-.
day. •
I
_ I
. .0 40 e
..................."...".-._...--.."--..""--".".(SEAL)S (SEAL)
* Marold..J:._ ac tner......
L ..•••••-""..-••-"-"--_-.."-:.--.•••-•--•---."....•••------•----....-.(SEAL) X - (SEAL)
e Ma aret J. Pch er
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
as.
County.
authenticated this day of........................... 19 Personally came before me this 19thday of
October , 19-. 90 the above named
Harold J. Schachtner andMar~aret .J.
Schachtner
TITLE: MEMBER STATE BAR OF WISCONSIN
•
(If not,
authorized by § 706.06, Wis. State.)
to me known to be the person S.. who executed the
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
GUY T. LUDVIGSON,S_C_,Attorneys at Law
MarcIowao.~
Osceola, Wisconsin 54020
Notary Publ' ------Count , Wis.
(Signatures may be authenticated or acknowledged. Both My Commis, tp ( hot,, State expiration
are not necessary.) p~
date:..- 4~'tT'GW 19V--••)
*Names of persons signing in any capacity should be typed or printed below their siEnatures. n
WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc.
FORDS Na I-leis Milwaukee, Wis.
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SEPTIC TANK MAINTENANCE AGREEMENT
St Croix County
a
OWNER/BUYER
0
ROUTE/ BOX NUMBER ' Fire Number 0
ty
CITY/ STATE / ZIP
PROPERTY LOCATION:Section TZ/ N, R_Lq W,
Town of St. Croix Count ,
Subdivision- &Z Lot number .
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes.- Proper maintenance con-
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 a7 ect t e .unct on of tine septic tank as a treat-
ment-stage in the waste disposal system.
St. Croix County residents may be eligible to recieve a grant for
a maximum of 60% of the cost.of replacement of a failing system,
whit 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 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.
H
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
meet of Natural Resources. Certification form must be completed •d
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration date. Q
SIGNED lJ LI--
DATE
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
386-4680
Sign, date and return to the above address.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
-INOUSTRd', DIVISION
LABOR AND PERCOLATION TESTS (115) MADISP.O. BOX 76
ON WI 53707
HUMAN RELATIONS
(ILHR 83.09(1) & Chapter 145)
LOCATIO : SECTION: TOWNS HIP/k OOOUO xY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
SE'/4 SW 14 3 /T 31 N/111 ,K(or) W Somerset n/a n/a n/a
COUNTY: OWNER'S 8V3l!0(KXNAME: MA LIN DDR SS:
,St. Croix Barry & Susan Richardson 408 Cedar Ave. Apt. #3, Somerset. Wi. 54025
USE PATES OBSERVATIONS MADE
NO. BEDRMS.: COMM R L DESCRIPTION-Fri R O A O TESTS:
®Residence 3 n/a UNew ❑Replace I 10-17-90 n/a
RATING: S= Site suitable for system U= Site unsuitable for system
ONVENTIONAIMOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
conventional
A
®S ❑U [as ❑U ®S ❑U ❑ S BU ❑ S [
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
[under s. ILHR 83.09(5)(b), indicate: class 2 Floodplain, indicate Floodplain elevation: n/a
decimal' PROFILE DESCRIPTIONS page 2 OnC2
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTHXiX ELEVATION OBSERVED EST. HE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 1 7.00 99.53 none >7.00 1.08bl.1. 1.75bn.sil. .67bn.s.l. 3.50bn.l.s.
B_ 2 7.16 98.92 none >7.16 .83bl.1. 2.08bn.sil. .33bn.s.1. 3.92bn.l.s.
B- 3 7.50 99.37 none >7.50 .92bl.1. 2.00bn.sil. .58bn.s.1. 4.00bn.l.s.
B- 4 7.09 99.72 none >7.09 .67b1.1. 2.25bn.si1. .50bn.s.1. 3.67 bn.l.s.
B. 5 6.75 99.45 none >6.75 .83bl.1. 2.00bn.sil. .42bri.s.1. 3.50bn.l.s.
B-
PERCOLATION TESTS
TESL" DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD p D PER INCH
P-
P-
P-
SS&I r a
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 95.42
CS
~l^ . r oo u~ rn~ J9 P E_
^3 i I tH
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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:
10-17-90
HONE NUMBER(optional)
--Q-uy L. Steel ADDRESS: CERTIFICATION NUMBER: N15-246-6200
1554 200th. Ave., New Richmond, Wi. 54017 2298, CST SIGN RE:
e_lafhy
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD•6395 (R 10/83) - OVER
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SOIL FILL
DISTRIBUTIOI.1 PIPE
APPROVED S4WTHETIC COVCR
`
717 o r~r1AT Rl1~t- OR 9" OF STRAW
2' OF PiGGREGA1E OR MARSH HAy
OF a,/" AGGREGATE
EL E V. OF2, I G~f E!:-(_.
DISrRIBIJTIOU PIPE Tfj BE AT LCnST Cam- WCHES BELOW ORIGIIJAL GRADE
AQU AT LCASTLO IIJCHES BUT WO MORC THA1,1 42 IUCHES BELOW FINAL GRADC
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111 IMUM MF.M OF EXCAVATIOP FKO11 OR16V AL 6i(ji\K WILL BE . -171/2 INCHES
rtirrlrlvm ()qni OF EACAVATImN rAOM, CA~►(,IVJAL (jRAPF- WILL 6E - INCHES
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LIG E►JSC LJUMBE It:
DATE :