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PUMP CHAMBER ,
Manufacturer. /y 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:
i
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
B--d: ��hGd� /o. 4� Trench:'--'_
Width: //'may
/� Len�th:���� Number of Lines: 3 Area Built•(p�r
Fill depth to top of pipe: -�(Z -'
Number of feet from nearest property line: Front, O Side, Rear, Pt .2�
Number of feet from well: qQ
i
Number of feet from building: yQ
(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, 0Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: Plumber on job:
License Number: "� J
3/84:mj
`
Form - J S T C - 104
AS BUILT SANITARY SYSTEM REPORT
TOWNSHIP �'t" SEC. T 0-7 N-R Ih WW1
ADDRESS IK ST. CROIX COUNTY, WISCONSIN
� , 3 cry
SUBDIVISION �( k V rQ�Z.— LOT Q LOT SIZE C
PLAN VIEW
DistanceE and dimensions to meet requirements of ILHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
d Nerrh
I S y.str wk E V.
He .c
avray
7
0
6qo
r 3`
3 n'
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used / lot �;�� 4'i" AIUUCoi4�v^
"v Elevation of vertical reference point: /00.61 Proposed slope at site: a%y SLLJ.
SEPTIC T K: Manufacturer: 4111a S ¢Y" Liquid Capacity:
Number of rings used: Tank manhole cover elevation: �?'6"o
Tank Inlet Elevation: O Tank Outlet Elevation: 9410 g�
i
Number of feet from nearest Road: Front, Side,Q Rear, O -�o feet
From nearest property line Front,OSide,�Rear,0 / S / feet
Numb r of feet from: well S� building: /,9' t
� +,;-4bh1 5Lo co✓N w
(Includ this information of the above plot plan) ( 2 reference 3imensions to septic tank)
SEE REVERSE SIDE
T
OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION
4 po
4b
� 4 ° �� 1c�c.Q bs �o.,�sz �a (�.•rw„� t�c�.
Cco SS C{�, A- !e�+ isk- 0.N6 ba,�, tv-\- 60
re c A S� V�f
-WkQ- �Uv -16 (o azzko-OCA Or,
TO BE COMPLETED BY INSPECTION AGENCY
System design &/or permit on file? ❑Yes ❑No
Soil series per SCS Soil Survey: sheet #
Type of soil absorption system: ❑Below grd ❑At-Grd ❑Mound
Approx. size ' X ❑Gravity ❑Dose ❑Pressurized
Ft.2 ❑Bed. ❑Trench ❑Dry Well
Molding Tank ❑Outfall pipe
OBSERVED DEFICIENCIES ❑Other ❑Unknown
Septic tank
Setbacks: ❑House ❑Well ❑Prop. line ❑Other
Dose tank
Setbacks: ❑House ❑Well ❑Prop. 'line ❑other
❑Locking cover ❑Warning label ❑Pump/Floats "
❑Alarm ❑Elec. wiring
Soil Absorption System
Setbacks: OHouse ❑Well ❑Prop. Tine ❑Other
❑Ponding: ❑Discharge:
General comments:
INSPECTORS SKETCH OF -SYSTEM LOCATION
N
Inspector
Title
}
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
`<^ ST.CROIX COUNTY COURTHOUSE
911 FOURTH STREET • HUDSON,WI 54016
- - (715)386-4680
SEPTIC INSPECTION / WATER TEST REQUEST FORM
Specify desired test(s) & remit appropriate fee with application.
Outside water lines are often turned off during winter months,
making access to the home necessary. Please make arrangements with
this office to insure a time when entry can be gained.
Rater (VOC's) $185. 00 ❑ Septic $25. 00
Rater (Nitrate & Bacteria) $35. 00 (Visual inspection)
n
O er: Requested by J/ �— z5a�► s'
Address: Address:
City & State: City & St. ,
Zip Code: s5/Q/( Zip Code: ,
Telephone N°: Ojp_) 3,f-(Q.77S Telephone N°: ( )
Property address (Fire N2 & Street) : </
Lc cation: ,, ,, Sec.11 T N, R 11W, Town of
St . Croix Co. , WI. Tax ID N2 Parcel ID w .
H use color: Realty firm:
Lock Box Combo:
Water sample tap location: 6?�
TO BE COMPLETED BY PROPERTY OWNER
ROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS
Is the dwelling currently occupied? Yes 0 No ���
If vacant, date last occupied:
S ptiC system installed by: 0�7 Ye
S ptic tank last serviced by:
Previous Owner's Name(s) \
p �
Have any of the following been observed?
❑Y N Slow drainage from house. AUG 3
❑Y N Sewage Back-up into dwelling. 01993
❑Y Y�1N Sewage discharge to ground surfac ST CROOc
road ditch or body of water. 2Ct�f Gp, CV
❑Y Q�t Slow drainage from the dwelling.
❑Y N Foul odors. 9 '�
Other comments relative to system operation: 1
Xi C CA l`
I certify that the above information is complete and true to the
best of my knowledge. _._.
OWNERS SIGNATURE: DATE: J�/ /�
i
COMMERCI L TESTING LABORATORY, INC.
I 514 Main Street, P.O. Box 526
Colfax, Wisco sin 54730
715 - 962 - 311
800 - 962 - 5227
FAX - 715 - 9 2 - 4030
'I
ST. CROIZ COLINTY GOVERNMENT REPORT NO.* 48269/01 PAGE 1
CENTER REPORT DATE: 9/07/93 j
1101 CAR MICHAEL ROAD DATE RECEIVED+ 9/02/93
HUDSON, 111 54016
ATTN* AS Co NELSON
OWNEfi* Todd Frascht
LOCATION* 449 Brookwood Dr., Hudson
COLLECTOR: Jim Thompson
DATE COLLECTED* 8-31-93
TIME COLLECTED* 2*45pm
SOURCE OF SAMPLE* Outside tap
DATE ANALYZED*9-02-93
TIME ANALYZED:2SOOpm
COLIFORM,MFCC* 0 /100 at
INTERPRETATION* Bacteriologically SAFE
NITRATE-N* 5 ppm
Above 10 ppm exceeds the recommended Public
Drinking Water Standard.
_ I
Coliform Bacteria/100 ml
Nitrate- i trogen, mg/L
C.
s
sT ,fig
clgo
LAB TECHNICIAN* Pam Gave'
OFA DEPEN N
so WI Approved Lab No, 19
O ;
Means "LESS THAN" Detectable Level Approved by*
PROFESSIONAL LABORATORY SERVICES SINCE 1952
116,ERCO Laboratories
1931 West County Road 2. St.Paul. Minnesota 55113 Phone(612)636-7173 FAX(612)636-7178
LABORATORY ANALYSIS REPORT NO: 33228 PAGE 1 of 3
09/10/93
St. Croix County Zoning DATE COLLECTED: 08/31/93
1101 Carmichael DATE RECEIVED: 09/01/93
Hudson, WI 54016 COLLECTED BY : CLIENT
DELIVERED BY : CLIENT
SAMPLE TYPE DRINKING WATER
Attn: Mary J. Jenkins
CLIENT'S ID: T.Frascht
SERCO SAMPLE NO: 109743
SAMPLE DESCRIPTION: TFrascht
Sample
08/31/93
ANALYSIS:
------ --------------------------------- --------
Benzene , ug/L <1. 0
Bromob nzene, ug/L <0. 2
Bromoc loromethane, ug/L <0. 4
Bromod'chloromethane, ug/L <0.2
Bromof rm, ug/L <0. 5
Bromom thane, ug/L (Methyl bromide) <1. 0
n-Buty benzene, ug/L <0. 3
sec-Bu ylbenzene, ug/L <0.4
tert-B tylbenzene, ug/L <0.5
Carbon tetrachloride, ug/L <0. 2
Chloro enzene, ug/L < .
Chloro thane, ug/L (Ethyl chloride) <0. 4
Chloroform, ug/L <0. 5 ';
Chloro ethane, ug/L (Methyl chloride) <0. 6
2-Chlo otoluene, ug/L (o-Chlorotoluene) <0. 2
Imo° ..-,E-+•1- b
4-Chlo otoluene, ug/L (p-Chlorotoluene) <0. 2
Dibrom chloromethane u L <0. 4r=''"�
1, 2-Di romo-3-chloro ro ane u L <1. 2 r �
1, 2-Di romoethane, ug/L <0. 2 �
( thylene dibromide)
Dibrom methane, ug/L <0. 2
1, 2-Di hlorobenzene, ug/L <1. 0
( -Dichlorobenzene)
1, 3-Di hlorobenzene, ug/L <1. 0
( -Dichlorobenzene)
dnw Mx
x�
< means "not detected at this level" . 1 mg = 1000 ug. I
MEMBER
ERCO Laboratories
1931 West County Roac C2. St.Paul. Minnesota 55113 Phone(612)636-7173 FAX(612)636-7178
LABORATORY ANALYSIS REPORT NO: 33228 PAGE 2 of 3
09/10/93
SERCO SAMPLE NO: 109743
SAMPLE DESCRIPTION: TFrascht
Sample
08/31/93
ANALYSIS:
----------------------------------------- --------
1, 4-Di hlorobenzene, ug/L <1. 0
( -Dichlorobenzene)
Dichlo odifluoromethane, ug/L (Freon 12) <0.5
1, 1-Di hloroethane, ug/L <0. 1
1, 2-Di hloroethane, ug/L <0.2
( thylene dichloride)
1, 1-Di hloroethene, ug/L <0. 2
cis-1, -Dichloroethene, ug/L <0. 1
trans- , 2-Dichloroethene, ug/L <0. 1
1,2-Di hloropropane, ug/L <0. 1
1, 3-Di hloropropane, ug/L <0.2
2 ,2-Di hloropropane, ug/L <0. 2
1, 1-Di hloropropene, ug/L <0.2
cis-1, -Dichloropropene, ug/L <1. 5
trans- , 3-Dichloropropene, ug/L <0. 9
Ethylb nzene, ug/L <1. 0
Hexach orobutadiene, ug/L <0. 3
Isopro ylbenzene, ug/L, (Cumene) <1. 0
4-Isop opyltoluene, ug/L <0.5
( -Isopropyltoluene)
Methyl ne chloride, ug/L <5. 0
( )ichloromethane)
Naphth lene, ug/L <0. 2
n-Prop lbenzene, ug/L <0.4
Styren , ug/L <1. 0
1, 1, 2 , -Tetrachloroethane, ug/L <0. 2
1, 1, 1, -Tetrachloroethane, ug/L <0. 1
Tetrac loroethene, ug/L <0. 2
Toluen , ug/L <1. 0
1, 2, 3- richlorobenzene, ug/L <0. 2
1, 2,4- richlorobenzene, ug/L <0. 2
1, 1, 1- richloroethane, ug/L <5. 0
CKIM< me ns "not detected at this level" . 1 mg = 1000 ug.
MEMBER
ERCO Laboratories
1931 West County Road C2. St.Paul. Minnesota 55113 Phone(612)636-7173 FAX(612)636-7178
LABORATORY ANALYSIS REPORT NO: 33228 PAGE 3 of 3
09/10/93
SERCO SAMPLE NO: 109743
SAMPLE DESCRIPTION: TFrascht
Sample
08/31/93
ANALYS S:
----------------------------------------- --------
1, 1, 2- richloroethane, ug/L <0. 1
Trichl roethene, ug/L <0.4
Trichl rofluoromethane, ug/L (Freon 11) <0. 7
1, 2, 3- richloropropane, ug/L <0. 2
1, 2, 4- rimethylbenzene, ug/L <0. 2
1, 3 ,5- rimethylbenzene, ug/L <0. 3
( esitylene)
Vinyl chloride, ug/L <1. 0
Total Xylene, ug/L <1. 0
This sample's analytical results are / ot below the U.S. EPA's
SDWA Maximum Contaminant level of(?P" 30/91 for those requested
compounds which are also on the SDWA MCL list.
The analytical results in this report pertain only to the items tested.
All analyses were performed using EPA or state approved methodologies.
Samplet that may be of an environmentally hazardous nature may be
returned to you. Other samples will be stored for 30 days from the
date of this report, then disposed of by SERCO Laboratories. Please
contact me if other arrangements are needed. This report may not be
reproduced, except in its entirety, without prior written approval
from SERCO Laboratories.
Report submitted by,
J
Diane J. nderson
Project Manager
021< me ns "not detected at this level" . 1 mg = 1000 ug.
MEMBER
DEPARTMENT OF IN USTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
I
LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISON
' P'0:MIX 7869 BUREAU OF PLUMBING
MADISON WI 53707
NW14,SEi4jS17,T 9N—R19W CONVENTIONAL ❑ALTERNATIVE state Planl.D.Number:
(If assigned)
Town of Hudsoa Ing Tank ❑In-Ground Pressure ❑Mound
Lot 109 Park View Vtate IV
NAME OF PERMIT HOLDER: r ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Sam Miller �� Route 1 , Box 282, Hudson, WI 54016 7-1 -8 3 "vb
BENCH MARK(Permanent refe nc point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.:
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
Douglas Str hbeen I5932 St. Croix 92496
SEPTIC TANK/KOLDING TANK:
MANUFACTU ER: LIQUID CAPACI TA INLET EL V.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
P V ED: PROVIDED.
?"`� " YES ONO OYES VNO
BEDDING: VENT CIA.: VENT MATE.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
JALARM: FEET FROM 11 LI �l AIR INLET.
DYES NO DYES O NEAREST 7
DOSING CHAMBER:
MANUFACTURER BEDDING: LIQUID CAPACITY: PUMP MODEL PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED:
YES ONO ❑YES ON OYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROP ERTV WELL BUILDING VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET:
PUMP ON AND OFF) OYES ONO NEAREST
SOIL ABSORPTIONS STEM.Check the soil moisture at the depth of plowing LENGTH D AND MARKING
or excavation. (If soil an be rolled into a wire,construction shall cease until FORCE
MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYE TEM:
WIDTH LENGTH: NO.OF DISTR.PIPE SPACING: COVE INSIDE DIA *PITS IL IQUID
BED/TRENCH TR'I�CRES- I M AL:
PIT DEPTH
DIMENSIONS ( �
RAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NCF DI rR. NUMBER OF PROPERTY WELL: BUILDING: V NT TO FRESH
BELOW PIPES f( ABOVE COVER. EL%N' Tj EL ND PIP LI AI T:
Z E4 FEET FROM V
( Z NEAREST--► D
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
and furrows thro n upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
DYES ONO
OIL COVER ITEXTURE JPERMANENT MARKERS OBSERVATION WELLS
OYES ❑NO ::1 YES ONO
DEPTH OVER TRENCH/BED IDEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED S MULCHED
CENTER: EDGES: DYES ❑NO
DYES ❑NO ONO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH: NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER.
BED/TRENCH TRENCHES:
DIMENSIONS
M NIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL. NO DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING
EL V.. ELEV.. DIA.: ELEV.: PIPES DIA.:
ELEVATION AND
DISTRIBUTION
INFORMATION H LE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED f\ PLANS
OYES ❑N a ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: OBSNUTION WELLS: - NUMBER OF PROPERTY WELL: BUILDING.
Q(� FEET FROM LINE:
V� OYES ONO ❑YES ❑NO NEAREST
r�0
Sketch System on Retain in county file for audit.
Reverse Side.
SIGN TITLE.
DILHR SBD 6710(R. 1/82) �j., 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, usually every 2 to 3 years;
6. If you have questions concerning your private sewage syste: i, 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
L Property owner's name and mailing address. Provide the legal description where the system is to be
installed;
I!. Type of building or use served: IT 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
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 8Yz 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 ove, 2 years of steady negotiation and public debate. The groundwater bill Ground#.etef
included the creation of surcharges (fees) for a number o sf regulated practices which Wiscori; `5 e
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasute
is used in your building is returned to the groundwater through your soil absorption u
system or the disposal site used by your holding tank pumper.
a
The monies collected through thcase surcharges are credited to the groundwater fund adminis-
te,red by the Department of Natural Resources. These funds are used for monitoring ground- t
,ate , groundwater contamination in-estigations and establishment of standards. Groundwater,
is worth protecting.
SBD-6398(R.03/86)
Ta,L R 11 , SANITARY PERMIT APPLICATION. C'�d! X
In accord with ILHR 83.05,Wis.Adm.Code
� �• STATE SANITARY PERMIT#
99 yg4
—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 ®NO
PROPERTY OWNER PROPERTY LOCATION
A11 L/ e'/a$ '/a,S T.� , N, R E(OjT
PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER I BLOCK NUMBER SUBDIVISION NAME
R,�. Z p _
CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK
OA& 7/5- 4� r
VILLAGE: . c 8/ 4JOO 0,e TOWN
111. TYPE OF BUILDING OR USE SERVED: ` �• cow
Number of Bedro ms if 1 or 2 Family 3 OR Public(Specify):
Y
III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable)
1. a. NA New b.❑ Replacement c. ❑ Replacement of d.El 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 Sys em 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. �9Conventional b. ❑Alternative c. ❑ Experimental
II. 2. a. ❑Syste - 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. ❑seepage Trench c. ❑See a e Pit
2. PERCOLATIOt I RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per nch): REQUIRED(Square Feet): PROPOSED(Square Feet):
V '7J • , Feet A Private ❑Joint ❑ Public
VI. TANK CAPACITY Site
in gallons 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. RESPONSIBIL ITY STATEMENT
1,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans.
Plumber's Name(Print Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number:
Da& l. s fpfd� ern o0 M r- r� 3 .Z
( f 3Z3 3
Plumber's Address(St eet,Cit ,State,Zip Code): t Name of Designer:
TT + �# W- AI ` � IM � 4 weS 7� ��� �Jo � �j frd`.GePr)
VIII. SOIL TEST I ORMATION
Certified Soil Tester(C T)Name CST#
sfio s." /s4
CST's ADDRESS(Stre(t,City,State,Zip Code) Phone Number:
IX. COUNTY/DEPj kRTMENT USE ONLY
❑ C sapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps)
®Approved ❑ ner Given Initial rcharge Fee
A Jverse Determination
X. COMMENTS/R ASONS FOR DISAPPROVAL:
SBD-6398(formerly Plb 7)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber
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SEPTIC TANK MAINTENANCE AGREEMENT Ho
St . Croix County z
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OWNER/BUYER
ROUTE/BOX NUMBER je D Fire Number
CITY/STATE ZIP
PROPERTY LOCATION : #0 Z, _14, Section 1-7 T N , R 7LW
Town of /_/u '( Sc°-y1 St . Croix County ,
Subdivision Lot number L02
Impr per use and maintenance of your septic system could result in
its yremature failure to handle wastes . Proper maintenance con-
sistE of pumping out the septic tank every three years or sooner ,
if n eded , by a licensed septic tank pumper . What you put into
the Eystem can affect the function of the septic tank as a treat-
ment stage in the waste disposal system.
St . Groix. County residents may be eligible to receive a grant for
a maximum of 60% of the cost of replacement of a failing system,
whicli 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
main ained .
The roperty owner agrees to submit to St . Croix County Zoning a
cert fication form, signed by the owner and by a master plumber ,
,jour eyman plumber , restricted plumber or a licensed pumper veri-
fyin that (1) the on-site wastewater disposal system is in proper
oper ting 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
thre year expiration. y
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I/WE, the undersigned, have read the above requirements and agree c,
to maintain the private sewage disposal system in accordance with M
the standards set forth, herein, as set by the Wisconsin Depart- 'b
ment of Natural Resources . Certification form must be completed
and returned to the St . Croix County Zoning Office within 30 days
of the three year expiration date . �����
SIGNED E
DATE
St . Croix County Zoning Office
P. O. Box 98-
Ham ond, WI 54015
715- 796-2239 or 715-425-84'63
Sig r , date and return to above address .
APPLICATION FOR SANITARY PERMIT
STC - 100 I
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This applic tion form is to be completed in full and signed by' the'owner(s) of the
property be ng developed. Any inadequacies will only result in delays of the permit
Issuance. hould 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 a
Location of Property: (,3i -3�� Section , y-, T<25 N - R 42
Township _ S �
Mailing Add ream (,Zr
10 �i ��l0
Subdivision Name --?6/ k U
Lot Number
Previous Owner of Property _"bn—Ct0,
Total Size f Parcel 3
Date Parcel was Created ��
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? _ ly _ Yes No
Volume S and Page Number ��_ at recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
War Deed 7:)
tract
3. • Ot er recordings filed with the Register of Deeds Office
In addition a certified survey, if available, would be helpful so as to avoid delays
of the revs wing process. If the deed description references to a Certified Survey
Map, the the Certified Survey Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPERTV OWNER CERTIFICATION
I (we) a '6y that atC statements on this 6oAm cute true to the best of my (out) ,
knowte.dge; dmt i (we) am (ane) the owneA(s) o 6 the pho peti t y dea cA i.bed in .th i,a
i"6000,tion 6oAm, by vi tue 06 a wakkanty deed Aeeoaded to the 066iee 06 the
County Reg tee. o6 Deeds as Document No ; and that i (we)
pees entty the p�copos ed A to bon the sewage �Rr,&ys tem (oA 1 (we) have
obtained easement, to Aun with the above de cA bed pnopvLty, bon the
eonattu o6 band bystem, and the dame has been duty AeeoAded in the 066.tee
o6 .the Co RegiAten. o6 Deeds, ae Document No. •-.�Z�) ,
SIGNATURE •F OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
i
DATE SIGN DATE SIGNED
1
PARK , E VY ESTATES ���JRT�f AD�lT6�N
S t At SURAW ICN LOCATE IN'THE a nWWSEi4,CC nON 17, T294, Ra 9IN.,
-;FOO N:CP.RMSCN. ST C90X COUNTY, 1PbISCOWN1
C32TIiICAT OF:0WXT2trASV*ZR
STATY OF W NSL-I)
ST«c3t=C ;y )
Lu Y
- 2, De 11r A.Soiaeroe._b+�g tine dalq elecisd, quaiiflad'aad acting 7tmt Tststsuzas �
of tlta Town o Hudson, do ka+eby osztity that in accordance_ roeorda is tnx office,
l=ane ar+no paid taxes oz ayeefai assesxmeats as of on any Litm
i—LS4e4 is tho Plat of Park view ra t"s, Fourth Addition,
Beverly. T*hosow Town Treasurer
TOMf4 BOAR E R=SOLUTION
RS,SOL' D, that the Plat of Park Via- Eatates fourth Addition in the Town of
Hodson, Parr 1 E. Wart and Bays A. Wert, ^•anera, is hereby approved by the
'Tore Board, /
Lwa is-A roved own rman -may
D ig ad ' own l,na:rman
i aareby to-t4y that Lhr forrgoinq a a a:opy 01 resolution adopted by the Town
Board of the T wn o1 f-ludson.
"to own Clerk
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OWNI8St CeR IFICATE OF DEDICATION
As o-ne s, we hnraby certify that we caused the land described tin thi: Plat to be
6;urv*T-4, ' ad, r=apped and d4dteatn4 as r"resenthd on this Plat. W4 +loo certify
that :2:4a Fla: 1 P required by S. 236.10 or S. 230,12 to be submitted to tiie foitowing for
approval or ob action:
Dspart at "i *Development
iieoartm nt of Industry, Labor and Human Relatio:s,
Town o1 Iudson. City of Hudson and St, Croix County,
W;TN?S,. the hand and seas of said owners this day of
In�ese ce of:
-� Darrel art '
Beverly
I
STATE OF WIS ONSIN 53
ST. CROIX CO N•f Y
Personal y came before me this day of //:may /, the above
rwunwl Darrel T. W er t .end Beverly A. W art, to me known to be the persons who executed
the foregoing ir strument and acknowledged the same,
Notary Pi blica i i, 2, Wisconsin My commission expires
blary tsch, Notary Public
_l
CIRTIFICATE OF' TOWN CLERK
^:STTATE OF WISCONSIN)
ysr. CROIX CO 'NTY }
I, Rita;ior,e, being the duty appointed, qualified and acting Town Clark of the
Town of tirdso , do hereby cozify that copies j of this Plat were forwarded ax
required by .t, 30,12 on the day of 1994, and that within
the 20•da as b y lir set by e, 236;f2(3)(no objects na to the plat have boon filed)
(all o h., r.,at have been mrt).
z, 3/if J[r�R� CTC9i�rt R„/
Dace Ait'X Horne, Town Clerk
JAIMAES E. RUSCH
HUDSON, WISCONSIN
THIS INSTRWFHT CRAFTED 61
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na •a„♦ � ' u✓r tpw�f'C"'�C 3`tki��4,,,��,i} ti 1 ` �G .. ,k^r —_ y .s. .,1 Ys� - w � ,�;.,,_,._._�.
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3URY2TO18tS CERTU'ICATS.-
Y,35tisas39.iLaeoby Roj istemod WL""Wis I.-ad Susveyov, bsxahy Certify to the
beet of myprofe*aiooal knooleftes underetao4mg and belief'
Th".2 have esrvey*•ui,divtdei and rnapp4d Park View£uates 7ourth Additiou,.
looted Is the NSI/4 of the SW 114 and the N Cl l 4 of the SEI14 of 3eatioa 17, T29.4.
It 19W. Town.of Hudson. 9t. CroixCoasty. Witooneis;
That i have nand* such surve7, land divislos and pint by tb&di boesion of Darrel E.
We"&5d•Devsst7.A.West. owseve of said ISM, described as follows.
Commencing althe St(4 cower of said Section 17:themes,8996&""W (►ssu nod
b*&xiago sefosesged'to the tswaumasted ZA3T.t!EST 1/4 3ecUoa Use a 34etion t 7.
be*sise assura"SS9"U'04'W)(recorded as 369'2 1140"W on thes Certn-sd Survey Wap
recorded in Voinseo 1,,Pete l94). 1332.981,sloag said FAST.W ZST'1)4 hoodoo Heat
ti, - S4'06t30"W-221.7.3 ttstb.plea of b.gi&&iwt:tsenae Ny►S2840"ir 412.008;thence..
NV"j30"E 212.00+to the Seuthorly right-of-,ray line of Ore*&UJU Lane.thence Y
?131P%2440-W 66.001,along saidr4kt•ol-oW7 Us*. thomce W94830"W 251.404;thsace
57V3615Z"W'194.359;th^oc*S89115tl4"W 216.764;thence NWS7405"W /42.17t:thence
S89s168t4 W 554.00g.--UW=*N006130"E 104.0Ott tbeass 389813tl411'M 3►4.0Wi thems.
NU wr30"L'.154,001,;tbeece 589.15114"W 66.011 thence SO`Ob630"W ]16.334:thence.. '
309"ISt14'!tp'13 i.t101,;.ehence NO.3715I-W 54.198;thesca 599.22"1W'l4t..308t thence
S0'06130"W.204.48s:tbeoce N89'151 14"E 150.008;those*Sdto6830"W 31L.972;sheet•
N89s,2S114!'L 150.QORt-thence Soatheaetexly 66.231 aleuty�t the►sYS-of&.383.008 radius
easw'e000siYa:Nostheaatsrl7 wheee chord bearsS4'SOt50"TE '17,f;themce Vt9'15014"E Y
57.0161 tltenae Southeaste7ly_136.162&Iona the arc of a 31T.001,'sadlus eorvo coeeave
Nostbeatterliyy♦chose,chord bears S24 03102"E M.518t thence 8302383012: 143.141:
themeMTl'36PWE'16o.961f thence NSIPIS414"E243.008;thsme Se068311W l0s.Y70t;
tbereo S&V36130'W..2".141,thence Southeasterly 96.141 al the are of a 2 17.008 ;.
r -i=WVO eeoeave Northeast*ely.whose chord boar 378`03816"t 95..Sst tS&nee
Hvr! wz 920.W;thence'Nerthoastezly 91.21''•along the ar*'.of s 300.f1Ot radius
eus+i soseaw NorthwetesIp weose'cbord bears NW32s40'7 ".SSS;tb*xgca North-.
westavirs'.'441along the'are of a 309.008 radius curve eameavw Northeastarly what*
ebo"bear*`T1W37s26"W 91.098:thence NO"04t30"2 130.001;thence NWIS"14^ �
478.0121 tlsanco W061,30"E 834.561 to.the poin4 of begisnins..
Tbwt•sae14 plat is.a correct repro 8oatation of aL the exterior boesdeaies of the
Lend wsrreyo4 and the subdivision thereof wade, and
Zhae I
have Idly oormpiied with the provisions of Cbapt*r 236 of the BNteeonsta
SL+Wrta*,tM$"visl**and Zoning Regulations of St. Croix Cammty, :!5,o:own of
tf+rdsoa lwhdivts,faa Ordinance.&ad the City of Hudson Snbdivlsios and 71stu1ag Or4i-
aanca to awe r
., eying.fit*idlnS and mapping the naafi*.
Dated this'..._.dey of MMMG-s , 19114 9'yy�l 1
• 1t�lith
de, of Apr31. 1984. -� T
saes IC. asth - 7
421 SeZond street �t _
liatiws,W leconsla 54016
COUK"TREASURER'S CERTIFICATE
STA71r Or WISCONSIN) S3
3T.CROM COU"TT )
I, hooey Soar Livermore, being duly.chatted, qu&lifled and acting Irtseeurer of
St. Croix Coosnty, do hereby certify the*the records in my office chow m umredeem*d
"ISO les sad no unpaid tares or special sesesemonts as of, ��-
affecting the leads ineluded in the Plat of Ark View Yst*tes Fourth Addtten.
�'-P-1!' 7 � Wit✓ .. I
Date Xdunty Treasurs,s
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70MM COU'urrmt RESOLUTION
This plat is hereby approved by the St. Croix County Comprehensive Parks,
P lsnoing and?,oMniq Committ.Ye.
Date
L,3 84�
Admlal 1,t zator •
If Mid 213,WK
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S T C - 105 r
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SEPTIC TANK MAINTENANCE AGREEMENT ~'
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St . Croix County x
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OWNER/BUYER S�i/Y7 /�/� ���/ M
ROUTE/BOX NUMBER GV-E) / &0X z Z Fire Number
.CITY/STATE 'k/4", _ZIP Se'-"o
PROPERTY LOCATION: �/ k, /Y_ 3t, Section, T 'Z9 R W
,y
Town of#a S o N , St . Croix County,
Subdivisiongr,C 6// ca) S�Q �t 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 neede , by a licensed septic tank pumper. What you put into
the system can affect the function of the septic tank as a treat-
ment eta a in the waste disposal system.
St . Crot County residents may be eligible to receive a grant for
a maximu of 60% of the cost of replacement of a failing system,
which we in operation prior to July 1 , 1978 . St . Croix County
accepted this program in August of 1980, with the requirement that
owners o all new systems agree to keep their systems properly
maintain d .
The prop rty owner agrees to submit to St . Croix County Zoning a
certific tion form, signed by the owner and by a master plumber ,
journeym n 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
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 sta dards set forth, herein, as set by the Wisconsin Depart- b
ment of Natural Resources . Certification form must be completed
and returned to the St . Croix County Zoning Offkre within 30 days
of the three year expiration date.
SIGN
ti
DATE
St . Croix County Zoning Office
P.O. Box 98,
Hammond WI 54015
715-796--2239 or 715-425-8363
Sian, d to and return: to above address .
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INSTRUCTIONS FOR COMPLETING FORM 1l5 ' SBD 6395
To-be m complete and accurate soil test,Your report must include: .
1. Complete legal description;
2� The use section must clearly indicate whether this is residence orpomne,nia| project;
3, K;ANK8UW1 number of bedrooms or commercial use, planned;
4, h this a nptoio, r:p|o*oment,ymam;
5� Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL
OTHER SYSTEMS ARE RULED OUT BASED 00 SOIL CONDITIONS;
G� PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan;
7� MAKE A LEGIBLE diagram acrurcu°|v locating Your test locations. Drawing to scale in preferred. A
separate sheet may be used if desire(,];
8, Make �ue your benohmark arid vmtira\ elevation roforence point are clearly shown,and are permanent;
Q� Complete all appropriate boxes as to cl,tvs' names,addresses, flood plain data, percolation test vxemn'
Linn' if appropriate;
)O, if the information (such as Mood plain,elevation)doee riot apply, place N.A. in the appropriate box;
11. Sign the form arid place yo", vu,mnt address arid your certification number;
12 Make |egib\e copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE
LOCAL AUTHORITY WITHIN 30 DAYS OFCOMPLETION.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Soil Separates and Textures Other Symbols
St — Smno (over 1['') BR — Bedrock
cob — Cobble (3 10'') SS — Sandstone
g, — Gravel (undc, 3^) LS — Limestone
°, — Sand HGVV — High Groundwater
co — Coarse Send Pero — Percolation Rau,
medS — Medium sand VV — Well
1s — Fine Sand Bldg — Building
|s — LvamySand — GreuterThao
°s| — Sandy Loom Less Than
°| — Lvan` Br) — Brown
°d| — S||z Loam B| — Black
,i — Sill Gv — G,nv
°d — "lay Loam Y — Yo||uw,
sd — Sandy Clay Loam R — Re,d
,io| — Silty Clay Loam mot — MotUox '
oc — Sandy Clay wx — wiU`
sic — silty Clay ^ fff — few, Fine,faint
°u — Onv cc — conmon. o*"m*
Lit — Pc,w, mm — r0any' medium
m — Muck d — diminot �
` n — pmm|ner�
HVVL — Hi8hweto, |eve|'
°
Six senn,a| soil textures surface.water
fo, liquid waste disposal 8K8 — Bench Mark
VHP — Verdca| Reference Point
/
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TO THE OWNER:
This mzi| texmportixflie first mapinxeczringaounhary permit, The county or the Dopartmommayrequwo
manfivadon of this nzi| tns� in the fie|d prio, t" pmrmit issunno:. A cump|ntu xo/ of p|ans b, the private
and a pormi/ mu�,tb* mbmittedro the appmmimc local outhmkvin order m
obmin a pwrm�
The oan}mry permit mu,; boobtoinod u:d po�t*d cxiorto hn start bfany construction,
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
INDUSTRY, DIVISION
AND PERCOLATION TESTS (115) MADISON WI 53707
HOMA N RfLAT10
- HUMA
(H63.09(1)& Chapter 145.045)
LOCATIONS SE TION: TOWN HIP LOT NO.:BLK.NO.: SU DIVISION NAME:
u� �/ �/ / 39 N/Rly C( ► ���dso,� v — /f 11BU/ f
COUNTY: OW ER'S/BUYER'S NAME: MAILING ADDRESS:
S a 7 .-ook j, sow GJ s, ryq,6
USE DATES OBSERVATIONS MADE
O.BEDRMS.: COMMERCIAL ESCRIPTION: PROFILE DES RIPTIONS: PERCOLATION TESTS:
Residence 3 t® d ;[Vew ❑Replace / �7
RATING:S=Site suitab a for system U=Site unsuitable for system Sm ro� �r (l 1,40, M
COENTIONAL: MO ND: IN G RSSTEM-1 L H G R / (motional)2 ❑ ❑u LKS ❑U YM EIS ®U WEI jAej d-)0A1.4 l J1 '
If Percolation Tests are OT required DESIGN RATE- If an �l
y portion is the tested area is in the
under s.H63.09(5)(b),i dicate: Floodplain, indicate Floodplain elevation: �/
PR FIL DESCRIPTIONS
0 4e-
BORING TOTALO EL OVATION DEPTH TO GROUNDWATER CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH
NUMBER DEPT OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B- / 76' / o.V e_ 7 ,S 3 B/Sl /.o Pjl s l s',oi- Br►S
B- ,S I / u.�► 7 ,�' f.l /.3 Sl A3
iyl yl 14Ade— 7 7.S-1 /1-3 S/Slo 18,7 S - .3 6107 ,/es, ly,(FAA
B-
PERCOLATION TESTS
TEST DEPTHS ATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER JI�JQ-I A TER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P- •s' o 6 6 --3
P- y. ' G.
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 ELE ATION 9S_- ? I
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/off �dr >�. .0 �.d.
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I,the undersigned, hereby certify that the soil tests 6r on this four%dyep made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code,and hat the data recorded and the s\\ re correct to the best of my knowledge and belief.
NAME(print): TESTS WERE COMPLETED ON:
6-
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional):
CST gzz:je
DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395 (R.02/82) —OVER —
i
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY&BUILDINGS
INDUSTRY, DIVISION
-
LABOR AND c P.O. BOX 7969
HUMAN RELATION I P RCOLATION TESTS (115) MADISON,WI 53707
(H63.090)&Chapter 145.045)
LOA I N: SECTION: TOWN s H OT NO.;BLK NQ.: S DIVISION NAME:T
s�NMI I( ) J w�
h u / �/ l / �9 rZ
COUNTY: OW ER' S N A A AD R S:
�' t
USE DATES OBSERVATIONS MADE
B CO M R TIO f
OLATION
Residence Blew ❑Replace I ,/ y� / ,/7 -
I �a•� ll OTy C'�C/
RATING:S-Site suitab a for system U-Site unsuitable for system Br SCI' ,�EJU r9s ou• M UND:Q� I(V �� _ :S S❑ M-1N-F�L ❑�G®� R�M(�cAZ��Ditt� l�tiogal) /S S f
]If Percolation Tests are 40T required DESIGN RATE-- If any portion of the tested area is in the
under s.H63.09(5)(b),i icate: I Floodplain,indicate Floodplain elevation:
PR FIL pESCRIPTIONS
BORING TOTAL• EL CATION P H T GR O UNDWATER CHARACTER OF SOIL WITH THICKNESS,COLOR, TEXTURE,AND DEPTH
NUMBER DEPT BS RVEDi ES PMH S TO BEDROCK IF OBSERVED(SEE ABBRV. N BACK.)
i
B- I 7,S -v e- 11 3 e s/ /,o 'sn s l 5,01 in S
7 BkS
B-3 .S' . 9 ' 7 ?xir 9/s lo 42, 6a sl
PERCOLATION TESTS
TEST DEPTH• ATER IN HOLE TEST TIME D IN WATER LEVEL-INCHES RATE MINUTES
NUMBER J,AICJiE6 A TERSWELLING INTERVAL-MIN. PER INCH
P.
P- ' G�"
P- .O' Ald L
P-
P-
P-
PLOT PLAN: Show local ions of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevati n reference points and s ow their IoFation on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION 9 9 '
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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 hat the data recorded and tike location of the tests are correct to the best of my knowledge and belief.
NAME(print): TESTS WERE COMPLETED ON:
' 6-
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ADDRESS: / CERTIFICATION NUMBER: PHONE NUMBER(optionaW.
row f� 7! S !J
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DISTRIBUTION:Original and one copy to Local Aut ority,Property Owner and Soil Tester.
DILHR-SBD-6395 (R.02/82) OVER-
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