Loading...
HomeMy WebLinkAbout020-1169-50-000 a c rY y O � I o I N a. et I 3 L'L � x I _o I c w o m O I I Cl) N Z y rn E Z 0 0 L z a Co r H � II' 0 O z 1t m z a c o z m m CD .N a (D o m 0 o Z m N z z I � N N O ?til 3 N d m �i w � o o a E E -° F_ _L U .. 0 0 2 0 •N ;� a a a n. c 0 o m co 00 0 rn = E i' R o o > =3 d D1 N N i33 O N o Ai O O O M N C O 00 N o c N o c = O O c o o Z a o 1 it C v C -z: CO N d N v V) G D (O 7 O N N lA O o ^ Z Z n 0 .M. �V ca d <0 a .+ C N ik � a • n d d m c A vat ' Oi PUMP CHAMBER Manufacturer: 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,0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: / Lenith: 9; Number of Lines:_ S _ Area Built Fill depth to top of pipe: fk� ' . Number of feet from nearest property line: Front, O Side, O Rear,Ol�t . Number of feet from well: E2 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 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: t 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• Dated• � s� f'd �� Plumber on job: License Number: ;. 3/84:mj ! Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ,(/t//,Cj ,✓oleVr'di„/ TOWNSHIP r 1-f-r SEC. {/ T r N-R -W ADDRESS �/P Nt� S�if/� ST. CROIX COUNTY, WISCONSIN SUBDIVISION A,V0.4 �re, LOT r LOT SIZE ►,-ss PLAN VIEW Distances and dimensions to meet requirements of I•IHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM e---- \.T I cos f� � I INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used C,� 0­0 Elevation of vertical reference point: IQC, . Proposed slope at site: ^ SEPTIC TANK: Manufacturer: Liquid Capacity: 11114140 Q Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: R-°- Number of feet from nearest Road: Front,O Side,@ Rear, O / feet From nearest property line Front 10 Side,O Rear,O feet Number of feet from: well building: / (Include this information of the above plot plan)( 2 reference dimensions to septic tank SEE REVERSE SIDE EP F INDUSTRY SAFETY&BUILDINGS DEPARTMENT O INSPECTION REPORT FOR LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O.BOX 796,9 BUREAU OF PLUMBING MA61SON,WI 53707 SEA, NW%, S7,T29N-R19W ECONVENTIONAL El ALTERNATIVE State Plan I.C.Number: (if assigned) Town of Hudson ED Holding Tank ❑In-Ground Pressure ❑Mound Lot 27-28 Ranchwood NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION ATE: Nels Anderson 516 5th Street, Hudson, WI 54016 1/y 1 BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.: Name of Plumber: P/MPRSW No.: County: Sanitary Permit Number: M William Schumaker 6382 St. Croix 95971 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY TANK�ET F/,��. TA/fy,,K�OUtT�MT V.: IWARNINU PROVIDED: PROVIDED.COVER (/I V�✓/ 1:1 YES LJNO DYES �i,JNO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH �( ( ALARM: FEET FROM �7 S LINE: INLET 1:1 YES NO 1 1 DYES ONO NEAREST V l 1`3 \/ DOSING CHAMBER: MANUFACTURER. BEDDING: ILIGUID CAPACITY: JPUIVIP MODEL: JPLI-PISIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: DYES ONO ❑YES ❑NO ❑YES 0 N GALLONS PER CYCLE: PUMPAND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING. VENTTOFRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET: OFF) ❑YES ❑NO NEAREST PUMP ON AND O ) U SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of lowin LENGTH DIAMETER MATERIAL AND MARKING p g FORCE or excavation. (If soil can be rolled into a wire,construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH: LENGTH: NO.OF DISTR.PIPE SPACING: COVER INSIOE CIA SPITS LIQUID BED/TRENCH TRENCHES: / M ERIAL PIT DEPTH DIMENSIONS ( � GRAVEL DEPTH FILL DEPTH IDISMPIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DI - NUMBER OF PROPERTY WELL: BUILDING: V NT TO FRESH BELOW PIPES: ABU E COVER ELEV.ILET.ELEV.END. PIPES: FEET FROM LIN Cj AIR INLET. (pI1 LP 100.3 i�C),(o� Z7 Z NEAREST--► , U �� T;7' 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- meets the criteria for medium sand. TIONS MEASURED. ❑YES NO OIL COVER ITEXTURE PERMANENT MARKERS OBSERVATION WELLS 1:1 YES 1:1 NO 1:1 YES ONO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED SEEDED MULCHED CENTER EDGES. DYES 0 N ❑YES ONO El YES 1:1 NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH. NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL. INO DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING ELEV.: ELEV.: CIA.'. ELEV.'. PIPES DIA.; ELEVATION AND DISTRIBUTION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION PLANS 1:1 YES 1:1 NO 1 ❑YES El NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL. BUILDING: FEET FROM LINE: ❑YES ❑NO ❑YES ❑NO NEAREST C7 Sketch System on Retain in county file for audit. Reverse Side. _..^ SIGNATURE: ) TITLE. .__ DILHR SBD 6710(R.01/82) Zoning Administrator INFORMATION & INSTRUCTIONS FOR COMPLETING A 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 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, us.uaJly 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: 1 Property owners name and mailing address. Provide the legal description where the system is to be installed; li. 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; Ill. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or repai r; 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 oves 2 years of steady negotiation and publie debate. The groundwater bill Ground�o r— included the creation of surcharges (tees) for a number of regulated practices which Wisco*n S can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasure o� is used it your building is returned to the groundvyater':hrough your soil absorption system or the disposal site used by your holding tafik pdPnper. The monies t jilected through these suraharges.are credited to the groundwater fund adminis tvred by the Department of Natural ResouTces. These finds We used for r-monitoring ground- f V;ate,, groundwater contamination investigations and establish,, rt of standards Ground vat', !, l:'s worts, protecting. SD-63�,8(R.03!36) D�LHR SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05,Wis.Adm.Code e STAT 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. 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. PETITION FOR VARIANCE DYES U NO PROP RTY OWNER PROPERTY LOCATION ac 6? S°,- %4 41,0'/4, S '� T' , N, R / E (or PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK 'f 'i", J'YUf VILLAGE TOWN OF7 II. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family y OR ❑ Public(Specify): III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. 9 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. W]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. X seepage Bed b. ❑Seepage Trench c. ❑Seepage 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): G� Feet §4Private ❑Joint El Public VI. TANK CAPACITY Site in alions Total #of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank Lift Pump Tank/Siphon Chamber ❑ VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system sh9wji on the attached plans. Plumber's Name(Print): Plumber's Signature:(No Stamps) P PRSW No.: Business Phone Number: Plumber's Address(Street,City,State,Zip Code): Name of Designer: VIII. SOIL TEST INFORMATION Certified Soil Tester( )Na a CST# CST's AD ( ee,City,State,Zip Code) Phone Number: Yd`7 as„� Bf Jje IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater Date Issuin Agent Signature(No Stamps) Approved El Owner Given Initial Su�?charge Fee Adverse Determination 14P I�� ��8 w X. COM14ENTS/RE SONS FOR DISAPPROVAL:� SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber APPLICATION FOR SANITARY P9RMtT STC - 100 i This application forty is to be completed in full and signed by the owner(s) of the property bring developed. Any inadequacies will only result in delays of the permit lr+r:uauee. Should this development be intended for resale by owner/contractor, ("spec 1►uuse"). then a second form should be retained and completed when the property is sold and submitted to this office with the appropria4a deed recording., - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property Wcat ion of Property 5k -AIV 1,-lte Section . _, T �- N ' g W 'row►►ship A olu MrIIIng Address -lot'sa/ Subdivision Name Z&(-AWOOd Lot Number __...___.__.._ ._....._.__. ..__ Previous Owner of Property Total Size of Parcel y G�-Cs�¢,4j Date parcel was Created Are all corners and lot lines identifiable? ..--. .G..-..- Yes �.., No Lb thin property being developed for resale (spec house) ? _ Yes No Vulume and Page Number as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Dead 1. Land Contract J. Other recordings filed with the Register of Deeds Office In addition, a certified survey, if available, would referencee helpful tosa Certified avoid Surveydelays of the reviewing process, If the dead description Map, the the Certified Survey Map shall also be re^,sired. r r .- e r r -O - -r r -. .r PROPERTV OWNER CERT-THrATICN I (We) eeAti.6N .that a t atatemente on th.i.e. onm the true de cotibed6iny'th,i,e ) k►►uwledge: VLat I (we) an (ane) the ownex(a o the pK ,�. 0 het a the tnSu4ma.tiun 6oAm, by vihtue o6 a w"�+�'1 ! de.Sd KecoKded .n fine. 66 6 Cvw t y Reg.i e.teeA o6 Deese ab Document No. and that 1 (we)) ea e.►itX own ,the,pn.opoe ed e.i to 6 on. the a eMQ a"4 p° 06 ter" tax 1 (we 1 iuty e �ta.i.nedyan eaaemen.t, to A" with the above desehibed p►lopeAtl• 604 the coplatAucti.on o6 said eyetem, and the same has been duty uc-onde).d in the 066•ice v6 .tile County RegiAta o6 Oetah, ab Document No, SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) rz DATE SIGNED ' DATE SICNIU I , #i►i�wl Lacs asidi�,a11 aM so" smW an a abate ` how* me appustawaat `? ` 4` '♦ � Me n=?TO w �io�N. t, 4_ k # y•w''. ONAW , j4gr t4, OEAWa ��.Ir 111.1 J •TATS OF YWWWCCNM st mil'• ,. r INd ■are► � -tt §: waooewal �� �� r r r.wa.are.► IM I* lanwweawalMl.� WWOPAPTWSV Iff air main ='i'•. • y. wy....•_ , 'Mlle r mod or�, My Oe�wMele� M /s M. W 00.. dew WN Fm �}y R �. alltiMMMtr Mw1!N IyMM w MMNM MMr 1NN Mir. iT lA�MwMNMIM "an fvwW►0.Mri W& A F F I D A V I T STATE OF WISCONSIN ) ) SS ST. CROIX COUNTY ) I, Harvey G. Johnson, Registered Wisconsin Land Surveyor, hereby depose and say: That l have located and noted the corner stakes of Lots 27 & 28 of the plat of Ranchwood, located in the SE 1/4 of the NE 1/4 of Section 12, T29N, R20W , and the SW 1/4 of the NW 1/4 and the SE1/4 of the NW 1/4 of Section 7, T29N, R 19W , Town of Hudson, St. Croix County, Wisconsin; That there is a proposed on-site liquid waste disposal system intended for, and a percolation test completed on Lot 27 of said plat; That said system is intended. to serve a home intended to be built on Lot 28 of said plat; Ana that I make this affidavit to inform all future purchasers of said Lots 27 and 28 of the possible existence of said system. Subscribed and sworn to before me this day of May, 1987 Notary Public, State of Wisconsin My Commission expires This instrument drafted by: Harvey G. Johnson � y S T C - 10 r' ' y ti SEPTIC TANK MAINTENA CH AGKCEMEN'1' St . Croix Purity i i y OWNEk/BUYEK� kOUTE/110X NUMBEk_-....1]. :�/�1.'CC�C� Fire Number CITY/STATE_/7livad � li, L it, S"Z/U/Co PkOPERTY LOCATION : lVk� Section' 'l' v21 N . K /2---W , Town of � �/�v,v . SL . Croix County . Lot n iamb eral-dL. I improper use, and maintenance of your septic bystcui could result in its premature failure to handle wastes . Proper u►ainLenance Cor► - stbts ut pumping out the septic tank ovary Lirree years or boon.-r , I it nu. dad , by a licensed aupt.ic tank pumpar . WIiaL you puL into the bybtem can affect the function o'f• t4w septic tank as a treat - ment stage in the waste disposal system. St . Croix County residents !ay be eligible to receive a grant for a maximum of 60Z of the coat of replacement of a failing system, which was in operation prL-u —.St . Croix County rccapted this program in August' of 1980, with the rL'yuirtitounL thit owners of all new systems agree to keep their systems properly maintained. •--- -- 1 The prupurLy owner agrees to submit to St . Croix County Zoning a certification form, signed by the owner and by a muster plumber . journeyman plumber, restricted plumber or a licensed pumper veri - tying that (1) the on-pits wastewater disposal system is in proper operating condition and (2) after inspection and pumping ( it 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. 0 3C I/WE. the undersigned, have read the above requirements and agree N to maintain the private sewage disposal system in accordance with M r, the standards set Forth, herein, as set by the Wisconsin Depart- Iv ment of Natural Resources . Certification form must be completed and returned to the St . Croix County Zoning Off:Lge 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 , P%EPARTMENT of REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS DIVISION INDUSTRY, c P.O. BOX 7969 LABOR AND PERCOLATION TESTS (115) MADISON,WI 53707 HUMAN RELATIONS (1-163.090)&Chapter 145.045) — - . SUBDIVISION w NAME: LOCATION.LOCATI N. SECT ION: TOWNSH UNICIPA =..'/w'/ 7 W - w aso E f COUNTY: OWNER E NAME: I I A � / A / STCRa�X CL� N4Ei!'SO� 5/6 STUSi HuD-_zS:)N WI USE DATES OBSERVATIONS MADE 7NO. DR COMM CIALDESCRIPTION:Residence — _ New ❑Replace n1NILG 11 /lit 7 MAee a .6 i qis K SQCZ _SAN r%A4o �r<S 4k aUrr 4 sol<s RATING:S-Site suitable for system U_@ Site unsuitable for system M"LR- prE0S0UjEJSxU1 ' RS T . M . IN G �� � Q�L DING TANK:RECOMMENDED SYSTEM ( tional► S �'oHV,� !V A L If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the 14A under s.1•163.09(5)(b),indicate: L!LAS'S � Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH NUMBER DEPP6, ELEVATION TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) 4 $c c-M 34" BIZ,j S L 23'' &N F-M.5 B- / �4Z /fig9Z > 9.4�- 7ThgeN L'rAeN FS i;' {�;I.LTs G' dept�.L iZ'L-r$eI'1 r t�F 4pd"6tnt�Y B- _Z /0 00 OO U3 N6N >10.00 F`�.Vco6 Iq Ge 4es' Y+k-t FS Cols f 'Sk4AL. W% B 3 /0'- L L-T� z�"LT$en 5 i L 13~Ra d RN f Y FS-*G R 3 oz.S7 ? 9.33 r a " - 04 wt, S LfflAw es y Z S' 8'k(LTSS i4''LT$e, <,o L 1' end M 5 ,6t B- �.Z UO.I ON> B- 7$3 7 9'�$CLTS Z��:Lr$e Sr L 8�$2nr s 30 RD-y 4 . r �sN f3 P5 JCc�i PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RAT MINUTES NUMBER lNettES AFTER SWELLING INTERVAL-MIN. PER INCH P. I A91- nNo 4.'2 30 3 P. z o o rcu.s© 3a �/ 7 .3 P- I 30 4 PLOT PLAN: Show locations)of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation I fference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVA 10 i�ll�aRy - 94,2 A'T�'e"ra' g7,00 srT� t� �a� LAI 0. 4�, I . I y H �µCiO LnT7� L 79 , -7 r UDS0N �' w6.' S��La✓ I Lour' 2 7 50' 1 - - - -- 1,the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME print): TESTS WERE COMPLETED ON: �JARVC`/ otd So Au 'L->U Y NC INC. MARL G /9%7 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional): se I& oh o CST SI�'i ATURE: DISTRIBUTION:OriginaPanri one copy to Local Authority,Property Owner and Soil Tester. 011-HR-SRO-6395 (R•02/$'') —OVER - i i c IF _ '41 p v� I 3