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HomeMy WebLinkAbout030-2009-90-007 3 C) o 0 m h 0. 0 o O c -o - - o E ¢ ° E r: c E E a -. o m o c o �a N 3 �, p E 0 y co N p a m 3w E (n om = —_ o O Q) � c5; a) 'o° �� ate> N E 0- c' @ @ co L w C N O N N O N U \y p U O N c S In .o p w Z N +� N U V U ,,- o � N O O 7 C6 O Z N 07 L LL 7 O C .f6 °0 3 O) N 'O p co ESL@. axi � �a i Z N O W E U) : 00 Z d a) ° a m M U) 0 c o z p Z 'U V� O fn P r O N Z '0 M O N � N N U CL •� aQ) U) O 0 m O O a) Q w Z co Z o N Z a rn y c CD N N d O tp L .. c n d 1 N p 0 �/� O (O G O a U N —�+ z � E l F _ 3. 3.. 3 Z O •► @ a a a ►"� _a 0 o � -0 y p W W 11� 7 Q N Vi J U 2 - m } U')v E J U m a d o o cn ,) (1) O cc cl 0 N N N 0 3 E N 5 `o E o 0 O o >>> O W ~ L (D c c d O') O v 00 � 0 O S N � m N 0 0 0 0i E E v ° • L' O M (n Z r- O Z � f- H � o � V1 y d o. �.( A 0 a O in V qq ST. CROIX COUNTY ZONING OFFICE 911 4th Street Hudson, WI 54016 Telephone - (715)386-4680 The St. Croix Co. Zoning Office offers the service of septic and water inspection to Lending Institution, Realty Firms , and private individuals. COMPLETION OF THIS FORM IS ESSENTIAL SO THAT THE PROPERTY CAN BE LOCATED. Please provide the following information, enclose appropriate fee made payable to ST. CROIX CO. ZONING, and mail, along with form to the above address. Testing will be done as soon as possible after fee and form are received. WATER TESTING--------------------------------FEE:$ 25.00 (For nitrates and coliform bacteria) - 4 - WATER TESTING--------------------------------FEE:$175.00 (VOC'S) SEPTIC SYSTEM INSPECTION------------ - --------FEE:$ 25.00 X PROPERTY OWNERS NAME: `71 vM4 5 G{n Cwaf li Ale"/.e loss PROPERTY OWNERS ADDRESS:_ /2 La /rc�I CITY: Legal Description SV✓ 1/4 , SE l/4, Sec. 3 , T 30 N-R /9 W, Town of $d.�/ou�� /,�rL6t. No901�9N9.�! Subdivis ion +-7 FIRE NO. A ZkL� A �°��` D� ✓ Color of house )3 rywn Realty sign? Firm: PLEASE INCLUDE, IF AT ?LLL POSSIBLE, A MAP, i.e. , COPY OF PLAT BOOK, WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET. Testing of residential water requires a sample that is fresh. If the home is vacant, and has been so for some time, the water line must be purged by running the water for several hours before the test can be conducted. WINTER TESTING: Many times water lines are turned off, or sill cocks are turned off, making access to the home necessary. If this is the case, please make proper arrangements with this office to ensure time when entry may be gained. � Cindividua�eq esting services: s Telephone--Noo - - _ p REPORT TO BE SENT TO: f/ faH / CLOSING DATE: Signature: ST. CROIX COUNTY '�,,�,. WISCONSIN ZONING OFFICE F� ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET • HUDSON,WI 54016 (715) 386-4680 Mar. 4 , 1992 Thomas Nettleton 1214 Co. Rd. I Hudson, WI 54016 Dear Mr. Nettleton: An inspection of the septic system on the property of Thomas Nettleton, located at 1214 Co. Rd. I, Hudson, WI was conducted on Mar. 4, 1992. At the time of inspection, the sanitary system appeared to be functioning properly. The inspection of this sewage disposal system was based upon a surface inspection of said system, and did not involve any excavating or chemical analysis . Accordingly, there is the possibility of hidden defects in the system not discoverable by this inspection. This does not in any way warrant or guarantee the continued proper functioning or operation of this system. It is recommended that the system should be pumped once every three years . Therefore, the prolonged life of this system may be dependent upon proper maintenance of the system. erely, , Mai-j—J Jenkins Assistant Zoning Administrator cj vn� 1494PacE 148 EX19TTNG SEPTIC 4E:*3- 2 evemF>tir AFFIDAVIT KATHLEEN H. WALSH Document Number REGISTER OF DEEDS ST. CRDIX CO., WI Name & Return Address RECEIVED FOR RECORD Thomas H and Gwen R Nettleton 03-06-2000 10:45 AM 1214 C-T_ I AFFIDAVIT Hudson WI 540 EXEMPT R CERT COPY FEE: COPY FEE- 030-2009-90-007 �a 3 n .-1 9 _3 R 6 I TRANSFER FEE: Computer I .D. Number Parcel I .D. Number PAGES:iN6 FEE: 10.00 PAGES: 1 The existing septic system which serves the dwelling being added on to must be verified by an acceptable soil report or be inspected by a licensed soil tester for compliance with high groundwater and/or bedrock separation requirements as set forth in s. Comm Chapter 83.10 (2) WI. Adm_ Code. The results of that inspection must be made available to this office. I£ the existing septic system meets these minimum requirements, and is properly functioning, an addition may be added to the dwelling without updating that system. This addition must not, however, encroach upon the required septic system setbacks as set forth in s. COMM 83.10 (1) . property owner(s) Thomag H and Gwen R property Mailing Address: w Property Legal Description: Lot # 1 _CSM/Subdivision SW —EL2/.. 36c. 44 Q_N-R�2w. Town of Josegh Coamnents: The existing septic system was sized and installed for a four bedroom dwelling. The building remodeling project will involve adding a bedroom in the lower level of the structure, and as such may result in septic system to be undersized for the structure being served. � erty, hereby affirm that the septic system te private sewage system codes. 1 I, as the owner of the above described prop serving this dwelling meets the above referenced sta realize that this addition may cause the existing septic system to become undersized for a dwelling of the resulting size, and I will make this information available to any future parties interested in purchasing this property. 4 __� �� Notary Public Subscribed and Signed: c sworn to before me on this date: _ O Date z 3 -G °o H ..... "V/,S,j Mjr commission expires. Zoning Depil�ctment ��- Approval:.�llllxu Date: 3-b- O-D y�b� S.V Thomas H.Nettleton • 1214 County Road I • Hudson,WI 54016 March 6,2000 St.Croix County Zoning Department 1011 Carmichael Road Hudson,WI 54016 Dear Sir or Madam: I am writing to clarify the room usage in the basement finishing project we hope to complete which adds three rooms now and one room in the future. Our intention is to have the following rooms: s I One(1)Bedroom(w/an egress window and closet) . Qge,(1)Exercise Room 1,( ),Family Room 4 06t(I),,Game Room(Future-This is not part of the current project.) We,,e rntact me on 715-549-5246(H)or 651-768-1512(W)if you have any questions or concerns. 7 Sincerely, Thomas H.Nettleton z u Homeowner `( i II t fU EXISTING SEPTIC SYSTEM AFFIDAVIT Document Number Name & Return Address Thomas H. and Gwen R. Nettleton 1214 CTH I Hudson WI 54016 030-2009-90-007 34 ,30 , 19 ,386I Computer I .D. Number Parcel I .D. Number The existing septic system which serves the dwelling being added on to must be verified by an acceptable soil report or be inspected by a licensed soil tester for compliance with high groundwater and/or bedrock separation requirements as set forth in s. COMM Chapter 83.10 (2) WI. Adm. Code. The results of that inspection must be made available to this office. If the existing septic system meets these minimum requirements, and is properly functioning, an addition may be added to the dwelling without, updating that system. This addition must not, however, encroach upon the required septic system setbacks as set forth in s. COMM 83.10 (1) . Property Owner(s) Thomas H and Gwen R Nettleton Property Mailing Address: 1214 CTH I Hudson WI 54016 Property Legal Description: Lot # 1 CSM/Subdivision CSM 7/1989 SW V4 —%, Sec._ 4 , T_�N-R 19 W, Town of St Joseph Comments: The existing septic system was sized and installed for a four bedroom dwelling. The building remodeling project will involve adding a bedroom in the lower level of the structure, and as such may result in septic system to be undersized for the structure being served. I, as the owner of the above described property, hereby affirm that the septic system serving this dwelling meets the above referenced state private sewage system codes. I realize that this addition may cause the existing septic system to become undersized for a dwelling of the resulting size, and I will make this information available to any future parties interested in purchasing this property. Signed: Notary Public Subscribed and sworn to before me on this date: Date: 3 -G - oa �n,,,.A,4, /,� , ae)0 0 Zoning Dep txaent �.P.• •.S�j My commission expires: Approval:, - _ A- c •' D01-- , Date• us SNP, "'. t� • tjPRS 3224 WI t MrCA 696 MN roe ' SHEET NO. OF 2 Timm CALCULATED BY DATE •M V//�� • Excavatin • CHECKED BY DATE R I, Box 192, Wilson, WI W27 SCALE 715-396-5443 ROGER TIMM 715-772-3214 ..... ; t ; I G lam, .......... .. _...._ lzoL y�,�dL,� 'F I yr t.. ..,.... ....i _ ; I ! -,- 1 ` I + i ffffff ` � I ! i I 1 i I i i ' 4 l ; I i i I� i i ... j ! i.. .. s __ ... .. i r ..................,_..1 ......:... ::_............. ....:..t....... l .... , ...�... I t ' 7 w I n�ooucrto�l nl�..sue•,w.mui. _ _ -- MFRS 3224 WI MPCA 696 MN • JOB 2 Z Timm SHEET NO. r� OF - .� /r C CALCULATED BY ' DATE Excavating Co. CHECKED BY DATE R I, Box 192, Wilson, WI 54027 SCALE ROGER tiMM 716-772-3214 , { I I } _. T ............ I I ................. I ' i _I ' I i I : 4 � . . _... I.__. . .__.L. ',,...... I i i i ; ......... ,... ._., .... I ; I : + I ,*— I .........'....... .... ........ �.. .. _a ..,..... i. j ! i } 1_.... }... I j ...'. I ...........�......... .. A. 1..... �......... ........ .F .. (....... 1.... ' .. ...... ......... _ 1 ..j ....r........ ...........t.........}.... .., j.........: ... ........... I........f..... i .......I... �...... I ... ..,. ..Gt:.. ..1 i....:... i + t ...........j......•...A...... .....j..........1.. .........i .....a. ... .... .... j 1. b....... } .....F.......... 1 ...... i J. ......_..f .....:...... ....... ............ ..........; ...... : ..... ...... ! ... ...+ I ... }i .... ...... . i. .... .i......... t i....... 1 .........�.. ' ..... I .... i ..... .. .I .... I .. ...._�. I I nroeicraau nMr.a��un� _ _ _- PROPERTY OWNER SOIL DESCRIPTION REPORT Page of PARCEL I.D.# Boren # Horizon Depth Dominant Color Mottles Structure 2 g Texture Consistence Boundary Roots in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. Bed ,Trench Ground elev. ft Depth to limiting factor in. ' Remarks: Boring # Ground elev. ft. Depth to limiting factor in. 35 5 Remarks: Horizon Depth Dominant Col Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell, u. Cont.Color Gr.Sz.Sh. Bed ,Trench Boring# ........................... ........................... ........................... Ground elev. 2q ft. Depth to limiting factor in. Remarks: Boring# E3 Ground elev. ft. Depth to Limiting factor in. Remarks: SBD-8330(R.07/96) Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include,but not limited to: vertical and horizontal reference point(BM),direction and percent slope,scale or dimensions,north arrow,and location and distance to nearest road. Parcel I.D.# APPLICANT INFORMATION - Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes(Privacy Law,s.15.04(1)(m)). Property Owner Property Location Govt.Lot 1/4 1/4,S T N,R E(or)W Property Owner's Mailing Address Lot# Block# Subd.Name or CSM# City State Zip Code Phone Number ❑ City ❑ Village ❑ Town Nearest Road ❑ New Construction Use: ❑Residential/Number of bedrooms Addition to existing building ❑ Replacement ❑Public or commercial-Describe: Code derived daily flow gpd Recommended design loading rate bed,gpd/ft2 trench,gpd/ft2 Absorption area required bed,ft2 trench,ft2 Maximum design loading rate bed,gpd/ft2 trench,gpd/ft2 Recommended infiltration surface elevation(s) ft(as referred to site plan benchmark) Additional design/site considerations Parent material Flood plain elevation,if applicable ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system ❑ S ❑ U ❑S ❑ U ❑S ❑ U ❑ S ❑ U ❑ S ❑ U [Is ❑ U SOIL DESCRIPTION REPORT Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. Bed Trench Ground elev. ft. Depth to limiting factor in. ' Remarks: Boring# Li Ground elev. Depth to limiting factor in. Remarks: CST Name Please Print Signature Telephone No. Address Date CST Number {� SANITARY PERMIT APPLICATION COUNTY U DILHR In accord with ILHR 83.05,Wis.Adm. Code STATE SANITARY PERMIT# —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER 8%,X 11 inches in size.. —See reverse side for instructions for completing this application. PETITION I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES NO PROPERTY OWNER PROPERTY LOCATION '/4, S ' T : , N, R IF, (or tW PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBERf SUBDIVISION NAME CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK E:1 VILLAGE : s II. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family. OR ❑ Public(Specify): III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. l New b. ❑ Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit## Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) 1. a.'91 Conventional b. ❑Alternative C. ❑ Experimental 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. ❑ seepage Bed b.,R]Seepage Trench c. See pa e Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): Private ❑.,Joint El Public Feet VI. TANK CAPACITY Site in aa ons Total #of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- LE glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank r " �' ' El L1 Lift Pump Tank/Si hon Chamber ❑ ❑ ❑ ❑ VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name(Print): Plumber's Signature:(No Stajmps) MP/MPRSW No.: Business Phone Number: Plumbers Address(Street,City,State,Zip Code): Name of Designer: VIII. SOIL TEST INFORMATION Certified Soil Tester(CST)Name r CST# CST's AODR S(Street,City,State,Zip Code) Phone Number: ( i IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) Approved I F-1 owner Given Initial Surcharge Fee Adverse Determination ` X. COMMENTS/REASONS FOR DISAPPROVAL: v SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County, Copy To:Bureau of Plumbing,Owner,Plumber i INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This sanitary permit is valid for two (2) years; 2 Your sartary permit may be renewed Lcf the expiration date, and at the time of renewal any new critet;a i ' e- Wit nsir: Administrative Code will be applicable; 3 All rr i;., �� Ihi.-, p„rmit must be app ,•. d by the permit s .iin authority. A ,c_w per ;il! r;'lay be needed ;f tilt -- r mange ire your building plans, systern location es' ;,;,ifed vvaste',',dte­ `lo✓v (nur-iber of bed- os sys`F rn_ or type of system: 4. Changue, O,�-rship cr -I:ember requires a Sanitary Permit Transfer/Renewal Form (SEC 5399) to be su :r ,4; . e . ty prior io installation, 5. Private systems must be properly maintained. The septic tank(s) should be pum„cri by a licensed Pumper °,vf j,-, :e( essacy. usually every 2 to 3 y:-ars, 6 It you h ,ve questions conc_�(ning your private sewage system, your local c(_ide itfn inistrator or the State of 'dVisconsin, Bureau of Plumbing, 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 where the system is to be nstall2d; i! Type of I,:wilding or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurart, fc: Fill in number of bedrooms if building is a one or two family dwe!linq. ill Purpose: of application: Check only one in ##1. Complete #2 if permit is for tank rep!ac:­1o1Y. reconnection or repa,r V Typ: c=f system: ct ,..,k ail appropriate boxes depending on system type- Check experiment-ii only if project s in (.Orlp.mction with University of Wisconsin; i! . ri _v_t�_ur, info, Oion: Provide all information requested n #1-6; ',�rrnatior r.!I ipacity of every new and/or existing tank, list the tot,; r �, to t o irl=;tailed. nrbc r of `anks ar-�3 r a �r , cturer's name. Indicate prefab or site constructed and ;a,r�i. ralz: i;:a; Complete a.r er and homing tanks for this systeir.. Check, ap�nava! only if Dk c.�;vec product appr;r✓a; Born DILHR. s; ,oC: qty st. `,” stalling plumber is to fill in name, license number with z.,ppiopr,atj prefix (e.g. P.1P. etc ), address and pho,ic number. Plrrrober must sign application form. Fill in designer �,ame if applicable, V!1!. Soil test information: Certified soil tester's name, certification number, address, ano, phone number. !X. County/Department Use Only, X Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than V/2 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; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement system areas, and the location of the building serves; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; frict"on 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. ------------------------------------------------------------------------------------------------------------------------------------------------------------ GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill Ground A tater included the creation of surcharges (fees) for a number of regulated practices which Wiscorr in'S a can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that burred reasure' is used in your building is returned to the groundwater though your soil absorption o system or the disposal site used by your holding tank pumper. a The monies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground- t water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD-6398(R.03/86) .,RTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS .,4DUSTRY, DIVISION LABOR ANL PERCOLATION TESTS (115) MADISON W 53707 HUMQIV RELATIONS CC (H63.09111&Chapter 145.045) d' LOCATION: SECTION: TOWNSHIP/�Y: LOT N BLK.NO.: SUBDIVISION NAME: SW 'IfE 1/4 34 �T30 M� t9 J(or►W St. Joseph *� n/a Henning COUNTY: OWNER'S ME: MAILING ADDRESS: St. Croix Steve Henning R.R.#2, Box 328A, Hudson, Wi. 54016 USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS:1PERCOLATION TESTS: ®Residence 3 n/a ®New ❑Replace I 11-10- 87 11-10-87 RATING:S=Site suitable for system U=Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM:(optional) S ❑U ®S ❑U IS ❑U ❑S BU ❑S E U conventional If Percolation Tests are NOT re uired DESIGN RATE: Q If any portion of the tested area is in the under s.H63.09(5)(b),indicate: n/a lFloodplain,indicate Floodplain elevation: na/ deciaml' PROFILE DESCRIPTIONS Page 42 ONC2 BORINGI TOTA DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR, TEXTURE, AND DEPTH NUMBER IDEPTH LEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B-1 6.92 100.24 none >6.92 .75bl.1. 2.17bn.sil. 1.00bn.cob.gr. 3.00bnn.c.s. gr. B-2 6.75 99.93 none >6.75 .50bl.1. 2.83bn.sil. .42bn.s.1. 3.00bn.m.s. B-3 6.93 99.77 none >6.93 .42bl.1. 1.67bn.sil. .92bn.cob.gr. 3.92bn.c.s.& B 4 6.83 99.83 none >6.83 1.00bl.l. 1.00bn.s.l. 4.83bn.c.s&gr. B-5 6.75 99.54 none >6.75 .42bl.1. 1.00bn.sil. 1.83bn.s.1. 3.50bn.c.s.&gr. B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PER155 3 PER INCH P- 1 .3.5C none 3 6 6 6 <3 P.2 3.79 none 3 31, 3 3 1 P-3 3.73 none 3 3-2 3-4 31 1 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 96.04 I 7 o i s _ol►m, too � °alb• �,� /�' ;�- - I � 3 ' 3 TN t s� �'� ` ae r 1 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 11-10-87 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional): 0988 N. Shore Dr. New Richmond Wi. 54017 229e, 15-246-6200 CST SIGN RE: DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —OVER —