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HomeMy WebLinkAbout020-1153-00-000 2 � a � A � k � ¢ � § � R � t � ( � � ■ � ) ) L { 7 � . � § � � i § E U) .9 @ 1 z / g § $ .. � § 2 _ 2 $ 7 ƒ § 2 @ � j § g f f r $ o e k z ƒ % k 2210 (D k © # Q & / > o 0 o a = � a k k E � § � # e a a a CL 2 'Wa k \ = k.\ 2 « 6 § $ \ 0 04 @ o £ co 0 � § � ƒ 2 5 § o . o k_kOD 2 k "0 } c » 4)§ G - @ ■ $ 2 § o , E Cl) _( Q 0g q ] ` � � ■ CL E $ c k a § . Q v a o 2 , , ` Form - S T C - 104 AS BUT-LT SANITARY SYSTEIS r.EPORT O NSR ,, sue �`7l(P�� /%Lr _ TOWNSHIP SEC. 2-3 T x N-R, :� W ADDSjSS � G +2 ST. CitOIX COUIiTY, WISCONSIN SUBDIVISION �O,t f/'4.�. '� LOT / n LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of ILHR 83 SHOW EVERY11111iG WITHIN 100 FEET OF SYSTEM 46 r , �� 4 I i f-rctlzc� �.k G�6 � fu INDIC}4 TE NO TH ARROW I pry BoxPSc� .. F 0 BSNCI MUM Describe the verticnl reference mint used ;l7it" & ri4 Ay `- Slaration of vertical reference paint: ,1 _ Proposed slope at�''site: / a SMtC TANK! Manufacturer: _ _ 4/l/ L!•luld Capacity: l Number of rings used: c) mnnlwl.e cover elevation: Tank inlet Elevation: _ _ Tank OuL.I,_t. l: rvation: ' Number of feet from nearr• i T:-:•nd Front,O t �,O Rear O feet . / '� From ncnrest• pLojjj .i ; i.1ne Ilrr�nt.1` ,ORear,O_��/� feet PUMP CEiAMER Manufacturer: �V f�' Liquid Capacity: . pump Model: pump/Siphon Manufacturer: _ Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trr.-,ch: Width: Lec�FLh: Number of Lines: 3_ Area Built:�� Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, O Rear,OTt Number of feet from well: Number of feet from building: (Include distances on plot plan). SEEPAGE PIT r ' Sizes Number of pits: Diameter: Liquid depths Bottom of seepage pit elevationt Area Built: Has either a drop box� or distribution box O been used on any of the above soil absorbtion sytems? (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, OFt._____ Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: plumber on job: Dated! �� - 6 - License Number: 3/84:mj DEPACTAENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING LABOR&HUMAN RELATIONS DIVISION F{.O.BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION MADI y�(I 53707 State Plan I.D.Number: SE.;,, , Sec. 23 ,T29-R19 ❑ CONVENTIONAL ❑ ALTERATIVE (If assigned) TTown of Hudson ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound F D . - ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Joseph Guertin lBradleVDr. Hudson WI 54016 4 B CH MARK(Permanent reference point)D SCRIBE IF DIFFERENT ROM PLA C REF.P .ELEV.: ST REF.PT.ELEV: WON4[06fit�rA ,/Yrv, NE Name Plu er: tr MP/MPR No.: County: Sanitary Permit Number: Roger Timm 3224 St . Croix 135361 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: I TANK OUTLET ELEV: WARNIN ABEL LOCKING COVER PRO D: PROVIDED: e S (] U C) /00 i YES [:]NO ❑YES NO BEDDING: VENT DIA.: VENT MA L., HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH l�. ALARM: FEET FROM LINE: AIR INLET: ❑YES NO ❑YES �NO NEAREST , 6) Cl Q SU DOSING CHAMBER: MANUFACTURER: I BEDDING: LIQUID CAPACITY: P PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ❑NO ❑YES ❑NO I [::]YES ❑NO GALLONS PER CYCLE: PUMP AND CO TRO S OPER IONA ; NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF YE ❑ NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture a he d Plth f pIOW ng RCE LENGTH: DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire,constru on s all c ase u til MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: BED/TRENCH WIDTH: LEFd NO.OF DISTR.PIPE SPACING: COVER INSIDE DIA.: PITS: LIQUID �� THE H S: MDa P: PIT ��" DEPTH: DIMENSIONS �l/ GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DI TR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELO PIPES: ABO C V R: ELEV.INLE ELEV.END: PIP S: FEET FROM LINE: \ AIR INLET: 91%1 Iq -99,q �- NEAREST >/00 / SCI MOUND SYSTEM: A% viol 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 I TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑YES ❑NO ❑YES ❑NO DEPTH OVER TRENCH/BED 7D=EPTH OVER T RENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: : ❑YES ❑NO I ❑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 I 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 El YES Q NO ❑YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: / ❑YES ❑06 El YES E]NO NEAREST- ''V i tL t l 1 ` Sketch System on Retain in county file f r audit. Reverse Side. SIGNAT E: TITLE: SBD-6710(R.06/88) SANITARY PERMIT APPLICATION LHR In accord with ILHR 83.05,Wis.Adm.Code !:V- STATE SANITARY PERMIT# –Attach complete plans(to the county copy only)for the system,on paper not less than El 6 8%x 11 inches in size. application —See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY46CPIGN ..J .S.E '/ /a,S Z 3 T ZF, N, R /q (or) PROPERTY O NER'S MAILING ADDRESS LOT# BLOCK# 40 CITY,STATE ZIP CODE PHONE NLI&4BER SUBDIVISION NAME OR CSM NUMBER II. TYPE OF BUILDING: (Check one) J CILL ` NEAREST ROAD ❑State Owned j' ❑,VILLAGE ❑ Public ,®1 or 2 Fam. Dwelling–#of bedrooms PARCEL 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. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1 A- Systern New 2. El Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. El of an 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 JR 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) G� ELEVATION (o mv loan �, `Dog `7_7 Feet /0 Zi / Feet VII. TANK CAPACITY Site in ciallons Total #of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Se tic Tank or Holdina Tank I X F1 F1 Lift Pump Tank/Siphon Chamber Vlll. 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 Sta ps) MP/MPRSW No.: Business Phone Number: �^ Plumb 's Address(Street,/City,State,Zip Code): IX. COUNTY/DEPARTMENT USE ONLY _j Disapproved Sanitary Permit Fee(Includes Groundwater a e Issued Issuing Agent Signature(No Stamps) Surcharge Fee) Approved El Given Initial ,�_ Adverse Determinationi /-Tj 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 INSTRUCTIONS �+ A � e 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. 1 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: I. 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. 111. 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. SSD4M(R.11/88) p • APPLICATION FOR SANITARY PERMIT STC - 100 his application form is to be completed in full and signed by the owner(s) of the roperty being developed. Any inadequacies will only result in delays of the permit ssuance. Should this development be intended for resale by owner/contractor, ("spec ouse"), then a second form should be retained and completed when the property is old and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - er of Property Location of Property - 3f k, Section 3 , T �'_N-R W Tovnship /durDSfli✓ Nailing Address Address of Site Subdivision Nme Lot Number Previous Amer of Property Cicvy c l,C= Total Size of Parcel Date Parcel was Created Z&_z Are all corners and lot lines identifiable? ,}' Yes No . Is this property being developed for resale (spec house) ? Yes No Volume and Page Number �i�_ 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 refer- ences to a Certified Survey Nap, the Certified Survey Nap shall also be required. PROPERTY OWNER CERTIFICATION I (too1 ceA.Li6y that aGC btatementis vrt thus 6onm ahe ticue to the but o6 my (owi) hncwtedge; that .I (we) am (ahe) the vwneA(b) o6 the pnopehty de�schi.bed in this .indolmaLion down, by v-chtue o6 a waAAanty deed conded in the 06 ice o6 the Coitn.tyy RegiAten o6 Veeds ass Document No. and that l (We) pheben.Uy nen I plopoaed Aite 6ok the 'sewage. CUAPOb e0tem (an I (we) have obtained an CdAc-ent, to kun with the above dehchibed phopenty, 6oh the conAtAuc.Gion o6 eaid Ayetun, and the game h" been duty necohded Xn the 066tee o6 the County Reg<.eteA o6 Vetch, ae Vocwnen.t ) . k GA c;- ` SI Oh OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED 4. Y AV Al l` _ � r .y 7 i4 s Ac f e3 H r S T C - 105 r H SEPTIC TANK MAINTENANCE AGREEMENT o St . Croix County z d 9 i OWNER/BUYER yip 6uew rn ROUTE/BOX NUMBER Fire Number CITY/STATE ZIP SC 123 i PROPERTY LOCATION : _ , , Section TN , R W, Town oftfiL1N , St . Croix County, Subdivision /bX K.4Ilt4y Lot number �d 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 septic tank pumper . What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St . Croix. County residents m_ y be eligible to receive 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 stems 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 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. Ho E I/WE, the undersigned , have read the above requirements and agree N to maintain the private sewage disposal system in accordance with x H the standards set forth , herein, as set by the Wisconsin Depart- ro ment of Natural Resources . Certification form must be completed and returned to the St . Croix County Zoning Office withJ 30 days of the three year expiration date . - SIGNED DATE St . Croix County Zoning Office P . O. Box 98 Hammond , WI 54015 715-796-2239 or 715-425-8363 Sign , date and return to above address . DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS I�(7USTRY, DIVISION LABOR AN P.O. BOX 76 HUMAN RELATIONS PERCOLATION TESTS (115) MADISON WI 537907 9 53707 (1-163.090)&Chapter 145.045) LOCATION: SECTION: OWNSHIP/�: LOT NO.:BLK.NO.: SUBDIVISION NAME: N/U E(or /o -- CO NTT W E R S Amt:: MA DDR SS: `> 6 USE DATES OBSERVATIONS MADE NO.BEDRMS : COMMERCIAL DESCRIPTION: R TESTS: '`�ftesidence 13 lKew ❑Replace !1A f ING:S=Site suitable for system Ua Site unsuitable for system ONVENTI NAC MOUND: IN-GROUN ESSUR : S STEM- N-FILLHOLDING TANK:RECOMMENDED SYSTEM:I:oS ou EIS au DS ou aS ou EIS ❑u ,�Y�x yar _ ,, «/ It Percolation Tests are NOT required DESIGN RATE: 4 if any portion of the tested area is in the under s.H63.09(5)(b),indicate: / Floodplain,indicate Floodplain elevation: PROFILE DESCRIPTIONS i MING TOTAL PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH dllt--tf3ER DEPTH IN, ELEVATION OBSERVED LST.HIGHEST TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) 13 / Z fuc �r62 .� 'l 'Z�r s' ' � �v r ls�a• LS 'ej 4 , ,/oleo of); B- Y /et�� .2l c /. WAW. U. ri r w B- S— Z y B- 6 ,7 UU1, • PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL—INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD p PER INCH P- P- P- ^P- 1 Max / /.P 2 P- PLOT PLA how Ida s 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. ,• i SYSTEM ELEVATION 1U. i .S EPi � r ` IN t 7/ ? S1,t ,f�s•/t Ott d�ft�ri/�� �>t'a[>` S�.••e i I 1YCj: >:'i7 •�j PkY< 1P il1 "O.-ex 1, the undersigned, hereby certify that the soil testes 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, • TAME(print l: DA FNEM TESTS WERE COMPLETED-ON: Licensed 3 33Te ter & umber �iii7f—tES'S Foggerty 8g CERTIFIC ION NUMBER: PHONE NUMBER(optionaW ROBERTS, its 54023 — CST SI AT RE: �22 Q J O' "ISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. ',II iIR-SBD-6;3-' c1.02/82) OVER — INDUS-r RYY,, OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUST CC DIVISION BOX 7969 LABOR HUMAN RELATIONS PERCOLATION TESTS (11J) MADISON WI 53707 (1-163.090)&Chapter 145.045) LOCATION: SEC ON: TOWNSHIP/MUNICIPALITY: OT NO.:BLK.NO.: SUBDIVISION NAME: '/4 '/ /T N/R E(or►W CnIJNTY: OWNER'S BUYER'S NAME: MA ILING ADDRESS: U_SE DATES OBSERVATIONS MADE NO. R CO SCR TIO w S: ! 1F B D iesidence ❑Ne ❑Replace I PROFILE DESCRIPTIONS:I PERCOLATION TIES rt FING:S=Site suitable for system Ug Site unsuitable for system 7NVENTIONAL: MOUND: IN-GROUND-PRESSU ST M-IN-FILL OLDING TANK:RECOMMENDED SYSTEM:(optional) I' `mss ou as ❑u os au ISEI s au as ❑u GI f Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b),indicate: I Floodplain,indicate Floodplain elevation: PROFILE DESCRIPTIONS f'.(irjING TOTAL ELEVATION DEPTH T GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH 11WABER DEPTH IN. OBSERVED EST.Hl G ES TO BEDROCK IF OBSERVED ISEE ABBRV.ON BACK.) B- -- yr /- , a' -"y'i�rt�nt� � �wriia�MNs — -,8,X�/f/w/�uGrll�, B-q 02 . / «/ re Z � AS B- 13- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD t p D PERI t73 PER INCH P_ P. P- 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 I ` I � I : i l ! TN j I j i i s ( 1• 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. Ni�ME (print): DOE TESTS WERE COMPLETED ON: UCensed 32Te#3289 Plumber 33 s uI'.iFIESS: F0 of y elg CERTIFI TIO NUMBER: PHONE NUMBER(optional): ROBES. WISCONSIN 54023 CST S, g.FkiR'E: DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. !)11-HR-SBD-6395 (R.02/82►; —OVER— —. G.1,/r/r "'JL .ems✓i ✓f `` . c7. tM i 1 p D i i Sr 3DniNE DAVE FOGERTY PLUMBING Licensed Perk Tester & Plumber 13233 ;$3289 Foggarty Heights Road ROBERTS. WISCONSIN 54023 Phone 749-3656 ` d i FiSst•�r•F /�"a.f 1 Q 6i r P � Sy,iY.y nrrr���f f - r 1 X ,� { v ��e Src� � ����, /U - 2 3 - f'�f i�'�"��e r "� .-,?-•-� /y1 P�!°S �i 2�1 71e 0 1316 Al 64 Z i. �., of use " 7 :r 1 6z- d t 1 • • J II d tr r g