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HomeMy WebLinkAbout020-1170-50-000 � � 4-J f� j / r» co g / / o \ \ \4J / \ / j . o to - < § m k m e � /: o =0 » / /n k ƒ 00 \ \ \ / / 7 m41 � k § / / \ » ? . / — � _ � .T A�/ � 3 / e m \ q \4 4-J / �)U3 � 0 0 f 7 � / } / 2 J / ? \ \ ( § o m ¢ _ P4 u o g ? -3 0 / % k k « 0 n o °4 ]% G E« g = w \ k e�° @ °= \ j/ \ Co - ' § a PO E E -4 K ƒ . m e = E ■- ° g / / £ i 2 22 \ / 3 o § © ° Cl. @ \ i O / / \ \ 2 ° / "M, § Z u Oro z 0 0 0 / � I:rg [G § § § e 00 m / CA CO) ■ _ \ CL E 77 � E / § \ \ 3 % \ CL ( 7 � c z - g ° Z § g § ® ■ § ) § CD k } / w a ± 0. / \ \ k E � � a / k % E R CD _ CL 0 { j 7 o _ 7 z , » % w ± � 0 ƒ z a ( � 7 � § � / 0 G § \ ° � / \ � i " Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ;``o,�;� r�,f r�_ TOWNSHIP �,/c, S'�.rJ SEC. T N-R W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION .� Y�NJ✓��r' Est LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•1- HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM A-- r � Lpi , LI S� 4v 'a ' - INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: �(sQ, Proposed slope at site: ,f SEPTIC TANK: Manufacturer: Liquid Capacity: /o e-, Number of rings used: Tank manhole cover elevation: i Tank Inlet Elevation: Tank Outlet Elevation: ' Number of feet from nearest Road.: Front feet I From nearest property line Front,OSide,ORear,(D feet Number of feet from: well Zeo , building: (Include this information of the above plot plan)( 2 reference dimensions to setptic tank) PUMP CHAMBER � r Manufacturer: r Liquid Capacity: Pump odel: P ^_ 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: Trench:_ j� 3 Width: Length: Number of Lines:_3 Area Built: gfd Fill depth to top of pipe: sl; 'r Number of feet from nearest property line: Front, O Side, O Rear,Q gt . 'r 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 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: kl"Vu� Dated: � �� APP` Plumber on job: License Number: 3/84:mj i I, 1 t r DEPARTMf_NT OF#NDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR&RWMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.U:'BOX 7969 BUREAU OF PLUMBING MADISON,WI 53707 SE'-,, NW-4, S7,T29N—R19W XXCONVENTIONAL ❑ALTERNATIVE State Plan I.D.Number: Town of Hudson ❑Holding Tank ❑In-Ground Pressure ❑Mound Lot 85-86-87 Edgewood Estates _ NAME OF PERMIT HOLDER'. AODR ESS OF PERMIT HOLDER: INSPECTION DATE: q ^ Hilory Cole 608 7th Street Hudson WI 54016 BE`�H MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF CST REF.PT.ELEV. .PT.ELEV.: . t Name of PI tuber IMPIMPFISW No.: County: Sanitary Permit Number: William Schumaker 6382 St. Croix 102836 SEPTIC TANK/HOLDING TANK: MANUFAC URER. LIQUID CAPACITY: TANK INLE7ELEV.. TANKOUTLET ELEV WARNING LABEL LOCKING COVER ie� h � PRO OED'. PROVIDED. 11 /4 �a /��s�/� f I/S i�� YES ❑NO ❑YES NO BEDDING: C. VENT DIA..t VENT MATL HIGH W ER NUMBER OF ROAD: PROPERT WELL: BUILDING l NTT FRESH I> '("" ALARM' FEET FROM LINE: ' ���*0 1v , (AIR INLE E1 YES NO 1 4 1 ❑YES ❑NO NEAREST DOSING CHAMBER: MANUFACTURER BEDDING'. ILIQUIOCAPACITY MP MODEL. PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ❑NO OYES ONO OYES ONO GALLONS PER CYCLE: My ND ONTR OPERATIONAL: NUMBER OF F.IAMI OPE RTV WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM E AIR INLET PUMP ON AND OFF) YE ❑NO NEAREST SOIL ABSORPTION SYSTEM.Check the soil moist rea he pt Of owing LENGTH TER MATE RIAL AND MARKING or excavation. (If soil can be rolled into a wire,co truction hal cease until FORCE MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDT LENGTH. NO.OF D TR.P SPr CING COVER INSIDE DIA -PITS 0E TU BED/TRENCH. i 1r �/ THEN s m RIAU PIT DEPTH DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR.PIPF DISTR.PIPE DISTR.PIP MATERIAL: NO.DI NUMBER OF PROPERTY WELL BUILDING VENT TO F 541 BELO PIPES ABOVE COVER E4EV.INLET ELEV.END PIPE FEET FROM LINE ' � D / AIR IN 0 db3 89 I 03i; 1 NEAREST ✓a7/ �d� /Vf/ MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- m ets the criteria for medium sand. TIONS MEASURED. ❑YES ONO SOIL COVER TEXTURE 1PIRMANINT All FRS OBSEHVATIONWELLS DYES NO 1:1 YES ENO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/ EY JDIJIPTH OF TOPSOIL 50 DDED SEEDED MULCHED CENTER EDGES. ❑YES F-1 NO ❑YES ONO OYES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH. No.OF LATERALSPACING GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR,PIPE MANIFOLD MATERIAL NO DISTR UIST R.PIPE DISTRIBUTION PIPE MATERIAL&MAHKIN(i ELEV.. ELEV.. DIA.. ELEV. PIPES DIA.: ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLANSCAL LIFT CORRESPONDS TO APPROVED OYES. ❑NO ❑YES El NO COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS: NUMBER OF L NE ERTV WELL'. BUILDING'. FEET FROM El YES 1-1 NO E]YES 1:1 NO NEAREST /• r 1 AN Sketch System on Retain in c8unty-#i4Jo audit Reverse Side. TITL• SI ATURE. E ' DILHR SBD 6710(R.01/82) Zoning Admi INFORMATION & INSTRUCTIONS FOR COMPLETING 4 SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This 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 1 criteria in the Wisconsin Administrative Code will be applicable; 3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 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. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Prcperty owner's name and mailing address. Provide the legal description where the system is to be installed; II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in ##1. Complete##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. 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. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. 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 8',/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 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. ------------------------------------------------------------------------------------------------------------------------------------------------------------ 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 ps.= ' included the creation of surcharges (fees) for a number of regulated practices which Wisco in*$* can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried re0941 $'. is used in your building is returned to the groundwater through 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) SANITARY PERMIT APPLICATION COUNTY T®ILHR In accord with ILHR 83.05,Wis.Adm.Code STATE SANITAR ER IT# —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 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES I NO PROPERTY OWNER PROPERTY LOCATION %, S T 9_9, N, R /� E(or ROPERTY WNE S ING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME N 91 CITY CITY,STATE ZIP CODE PHONE NUMBER �— VILLAGE: NEA EST ROAD,LAKE OR LANDMARK Lj:TO4 11. TYPE OF BUILDING OR USE SERVED: -�- t%o`� —//7/—Ca � 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. Z 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. 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.XSeeDage Trench c. ❑Seepage Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): `, ( 4 3 .S" 40 a [ Feet Private ❑Joint ❑ Public VI. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete strructed Steel glass Plastic App Tanks I Tanks Septic Tank or Holdin Tank ❑ Lift Pump Tank/Siphon Chamber VII. RESPONSIBILITY STATEMENT 1,the undersigned,assume responsibility for installation of the private sewage system show on the attached plans. Plumber's Name(Print): Plumber's Signature:(No Stamps) P PRSW No.: ' ess Phone Num Plumber's Address(Street,City,State,Zip Code): Name..Designer: Vlll. SOIL TEST INFORMATION Certified Soil Tester(CST Name CST# F 0 CST's ADD S(S et,City,State,Zip Code) Phone Number: IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sani ry Permit Fee V ndwater ate Issuing Agent Signature(No Stamps) harge Fee -&ahI_j Approved ❑ Owner Given Initial 11) ,,/( �d Adverse Determination GU X. C MMENTS/REASONS FOR DIS PPROVAL: SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION. Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber 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 e Location of Property S h �y uJ ' , Section , T 9 N-R W Township Mailing Address _j„� ,��`� Address of Site /c Subdivision Name . Lot Numbers Previous Owner of Property Total Size of Parcel a .� Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No Volume '7_q and Page Number � 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 Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (We) cenV6y that a t statements on thi6 6o4m ahe true to the best o6 my (oun) hnowfedge; that 1 (we) am (ake) the owner(s6) o6 the pnopenty desCAi.bed in this .in6oitmatdon 6o4m, by vixtue o6 a waAAanty deed neconded in the 066.iee o6 the County RegiAten o6 Veed6 as Document No. 3/ y�; and that I (We) phedentey own the proposed 6i.te bon the sewage dapoz sys em (on I (we) have obtained an easement, to nun with the above de6cAi.bed pnopeJrty, bon the eonatnuati.on o6 said eydtem, and the same had been duty neconded in the 066.ice o6 the County RegiAten 06 Veeda a,d Uoeument No. SIGMA Olt OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) TE ISIGN6 DATE SIGNED t gam' ...•.'N.. _ •• y x� GNAW • .M}.0 - .. .... .......................................... Nu •.•.• 4.N...r i .......-..- .•...... � r �� �` T�!��Ga�hr,fir a va1Mb1�yea - --• � � y. n vlr�wer1W wd Nhq i� ......L..�X.............. 8 � ;; • ! aSs�6�r iMMI Ot ftpmw zatatea, III Tom of sas i%r lift r. 3 � . 4 l ,..�R +w ap�urNaan� ...._ �! . �rrn ale bdo �i - - ....------ ---- "- �} s' aid" . ad ft"fwd dwr 0f owumbroom r.wi '. - _ Of 0 it aqy. l 00 "o . .Yi�fiy M�Mrs x al �. ..... _ y _. ... ..........................................Dald ... B !1. 'ld r ;; 4 ���li0i►llQx: � F STATS O?'WUMNSDj • ... #Yr sto. ocd,c_ _ °«' _ -'•"•"��V sN....... ......•,... . it. .� ... _ -. -,....'..+«w+w...w�... ............... ......... ..... - ._....j, ........ ..w. _ Is aW him AN VY - •�4h+5fr+iKY.wr�r ».w.v... i �• s.. . H N ' H a 9TC - 105 r a H SEPTIC TANK MAINTENANCE AGREEMENT ~ 0 St . Croix County x d a H OWNER/BUYER � I'p^�,e �,y�. �¢/ o' ROUTE/BOX NUMBER ��� /"/T �, /Grd}^�`� Fire Number .CITY/STATE ZIP PROPERTY LOCATION: ,, ;6, , Section, T %LqN , R__�f_W, Town of , St . Croix County , Subdivision 6;�-,7%ot number I 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 pdt 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 may 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 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 veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- eseary) , 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. 0 • E I/WE, the undersigned , have read the above requirements and agree N to maintain the private sewage disposal system in accordance with x M the standards set forth , herein, as set by the Wisconsin Depart- w ment of Natural Resources . Certification form must be completed and returned to the St . Croix County Zoning OffJre within 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 . • Z 0 C 0 • p ,1't �e4�i Z :� i4 T •.. � �. � �, �s sow o, rt �n z ea �i f• 't � • N Is IV 4r w ss &W 3: nay 047.1x•, nl�,cv,se s F � 3 to ' V EDGEW ESTATES F*GH VIEW F*.W 4k 01'25'41"E _457.40S Oi 25'41 OW 66 03 ' 500.00132.98' r=' 7. 3 - 298.37' �. ba N o 6A Z M o b& m o �I ..a cn �O r I v OD as .. V /0'( V ro — --_ — 132.98' lid S O1 2541"W m 97.00' 100.00' O ` �+ d S 01.25'41"W C ° Ic ( 156. 11 ' 30 .II I Z — — 132.98' d v� w 5'Cc 44Ry `^ o N . G i — 70 m , V I f too v < IN g of SEcaNA4ky c r� I 156. 11' o,e S 01 25 4 _... _ _ I � � w i W N p�iMgRy •P ppl -- 132.9 '41'W S 01'25'4 9 co S 01 25 I I ' m IGO 0 to i 134.. 19' ~ •I S O1 25'41"W M TMENT OF REPORT ON SOIL DIVISION RINGS AND SAFETY& BUILDINGS .IN�WUS DUSTi?Y, . LABOR AND PERCOLATION TESTS (115) MADISON WI 53707 HUMAN RELATIONS (H63.09(1P&Chapter 145.045) LOCATION:N• SECTION:T OWNSHtP UNICIPALITY: OT NO.:ILK.NO.: SUBDIVISION NAME: 5 F �i �19 (o W U so 87 '' EiE h E'S'T COUNTY: WNE MAILING ADDRESS: cy Cr Nu1Sonl Sr"Ro,x ' 42 �'401{s USE DATES OBSERVATIONS MADE NO.B : COMM TI O : I . Residence GUNK eNew C3 Replace l O,/ 3� 7 �V go,�_% Sates v_ A46 49 ll` V RATING:S-Site suitable for system U-Site unsuitable for system jqJ111.1 Q JCQNMENTIONAL: M . IN L OLDINGTA RECOMMENDED loptiOU ONv T10ryA1_ (optional) RIS OU I RTS ❑A N a M ❑U � If 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 I Floodplain,indicate Floodplain elevation: i� F-r PROFILE DESCRIPTIONS BORING TOTAL TO-GROUP D ATE -INCHES HA ASTER OF SOIL WITH THICKNESS,COLOR, TEXTURE, AND DEPTH NUMBER DEPTH U ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) -Fby MOTE r B- oa io4 .93 r 4 ./-7 1�'Bcs,crs 13" S, 19"Ro$IiSL S30-&T'-Ms 7 t61A 9"$c�TS /S YSt /5"R�e$tt+v StfGR B- 4 qz i64A A10 044 >8 .9Z zB"8i2NS ,e�'�a6 4o'�r,Fs �cc, . IB- dO S,�� ON .Og 22'B<<rs 4 "y$ChIS, 1W'efigM 4e MW�trws 491, B- ao a6.z'7 58 Z4'$t-LT5 46'�S,L "ki fhs scot, 7 o MoT 7"4 4-6 eF'S B. PERCOLATION TESTS TEST 0 PTH WATER IN HOLE TEST TIME LEVEL-INCHES RATE MINUTES NUMBER IRS AFTERS ELLING INTERVAL-MIN. PER INCH P_ P. Z 2761 NONL /oS,S U P- "LOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- rontal 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 /0Z.90 Pfu r l :y i Ptt�s-ra - E '/ _. { ^' � Ste• t N 'Sc4Ld $i � Jol� ,ES r EAR f:EC�+r+LMdS 2►NG SySTEM� I,the undersigned, her y certify that the soil tests reported on this form were made by me in ac rd with the procedures and methods specified in the Wisconsin Administrative Code,a that the data recorded and the location of the tests are correct to the best if my knowledge and belief. NAME print : n TESTS WERE COMPLETED ON: /�A� y �o�c� 5c,ty USCG R Naq 30 i9%7 AD RE.SS: CERTIFICATION NUMBER: PHONE NU B'ER(optional): ZAd7 ����NA �Ds�^/ 1 5.4616 34?-4 �6$p CST SIG ATURE: /K DISTRIBUTION: Original and one covy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02182) OVER - IVI-? / 4s-r 2?77 F<7- 2�fl at lrla�so.r✓ All 92 C16 C- q D � k � � l � ��-