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Parcel M 26.30.19.259A-05 030-TOWN OF SAINT JOSEPH Current X ST.CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): *=Current Owner *BADER, BRETT E&MARY M BRETT E&MARY M BADER 719 132ND AVE HUDSON WI 54016 Districts: SC=School SP=Special Property Address(es): *=Primary Type Dist# Description SC 5432 SCH D OF SOMERSET SP 1700 WITC Legal Description: Acres: 0.000 Plat: N/A-NOT AVAILABLE SEC 26 T30N R19W SW SW EXC CSM 7/1900 Block/Condo Bldg: (REPLACED BY)CSM 8/2170&EXC CSM 17-4485 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 26-30N-19W SW SW Notes: Parcel History: Date Doc# Vol/Page Type 03/25/2003 714505 17/4485 CSM 2004 SUMMARY Bill M Fair Market Value: Assessed with: 5367 Use Value Assessment Valuations: Last Changed: 07/08/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.000 38,400 192,200 230,600 NO AGRICULTURAL G4 25.050 4,500 0 4,500 NO PRODUCTIVE FORST LANC G6 5.000 13,400 0 13,400 NO Totals for 2004: General Property 31.050 56,300 192,200 248,500 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch M Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 -�� �- ���. ✓ �Q,�2Pr ScJ� s`✓� S �� T3Q /� /9/,f ?�o�./,�/ of s T�os�P�L---. yte 51C S �v J 'W� eI) � r � 6 'p- C, � G G t 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: l Leng'th: SJ" Number of Lines:—_? _ Area Built: Fill depth to top of pipe: S e` Number of feet from nearest property line: Front, O Side, /0/ Rear,0 Pt .f�Ql Number of feet from well: �// Number of feet from building: Gam ' (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: Dated: 77 Plumber on job: License Number: 3/84:mj pp- Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ��,� J/ TOWNSHIP , '7��?�-F�/f SEC. T `73d_N-R W ADDRESS ST. CROIX COUNTY, WISCONSIN w SUBDIVISION LOT _--- LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•1HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM f i �F INDICATE NORTH ARROVI BENCHMARK: Describe the vertical reference point used G�! Elevation of vertical reference point: ���'/. Proposed slope at site: SEPTIC '"ANK: Manufacturer: Liquid Capacity: 1�fr_ C7 _ Numl'er of rings used: Tank manhole cover elevation: _ Tank Inlet Elevation: Tank Outlet Elevation: Numter of feet from nearest Road: Front 10 Side,®Rear, 0 /� _ feet From nearest property line Front 10 Side 10 Rear,0 ez feet j14 d'r Numb:r of feet from: well _� building: IF (Tnclude this information of the above plot plan)( 2 reference dimensions to septic rvlr) ;' .TERSE S' �DEPARIf,4ENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&B DIIVISION LABO)t!&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMBING P.O.BOX 7969 MADISON,WI 53707 SW1,4, SW',4,S26,T30N-R19W PCONVENTIONAL ❑ALTERNATIVE state Plan l.D.Number: IIf assigned) Town of St Joseph [:1 Holding Tank E:1 in-Ground Pressure El Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Bret & Mary Bader Route 2, Hudson, WI 54016 f0-219- <2'�Z 0 BENCH MARK(Permanent reference poim)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: ICSTREF.Is ELEV.. Name of Plumber: IMP/MPRSW No.: County', Sanrtar PPermn Number: William schumaker 6382 St. Croix 102797 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELE V.. ROVIID DLABEL PROVIDED OV ER ❑YES ❑NO DYES ONO BEDDING. VENT DIA.. VENT MAT_.: HIGH WATER ROAD'. PROPERTY WELL BUILDING VENT TO FRESH NUMBER OF LINE (AIR INLET ALARM FEET FROM : YES ONO OYES ONO NEAREST DOSING CHAMBER: MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED: PROVIDED ❑YES ❑NO ❑YES ❑NO ❑YES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING AER INLET FRESH (DIFFERENCE BETWEEN FEET FROM LINE PUMP ON AND OFF) DYES ❑NO NEAREST SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH DIAME TER MATERIAL AND MARKING or excavation. I if soil can be rolled into a wire,construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH- LENGTH NO.Of DISTR.PIPE SPACING COVER INSIUE DIA =PITS DEPTH BED/TRENCH h TRENCHES MATERIAL' PIT DEPTH DIMENSIONS V GRAVEL DEPTH FILL DEPTH UISTH PIPE DISTR.PIPE DISTR.PIPE MATERIAL'. NO.DISTR. NUMBER OF PROPERTY WELL BUILDING VENT TO HEST-11 BELOW PIPES ABOVE COVER. ELE V.INLET ELEV.END'. PIPES LINE'. AIR INLET FEET FROM NEAREST 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 ❑ND PERMANENT MARKERS �E]SOIL COVER TEXTURE ❑YES ❑NO NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED IDEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER EDGES. DYES El NO ❑YES NO DYES El NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH. NO.OF jILATERAL SPACING GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR,PIPE MANIFOLD MATERIAL NO DISTR DISTR.PIPE DISTRIBUTION PIPE MATE VIAL&MARKING ELEV.. ELEV.. DIA.. ELEV. PIPES DIA.'. ELEVATION AND DISTRIBUTION VERTICAL LIFT CORRESPONDS TO APPROVE D INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLANS EYES ❑NO EYES ❑NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING'. COMMENTS: LINE FEET FROM / f%� ❑YES ❑NO DYES Q NO NEAREST A.c s.i ,�I Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE. TITLE Zoning Administrator ,BD 6710 (R.01/82) I 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..13 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. Property owner's name and mailing address. Provide the legal description where the system is to be installed: 11. 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; 111. Purpose of application: Check only one in ##1. Complete 42 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 81/2 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. ------------------------I------------------------------------------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more A� 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 c jer included the creation of surcharges (fees) for a number of regulated practices which Wisco SiW. can effect groundwater. The surcharge took effect on July 1, 1984. All of the water thaf buried reasuf e . 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 these surcharges are crediied to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground- . t WHtes g 0UP lwater contamination investigations and establishment of standa-ds Groundwater. s �c.rt�. protecting. SANITARY PERMIT APPLICATION CDONY 'n {� l� 5ILHM In accord with ILHR 83.05,Wis.Adm.Code �-" ``''��� STATE SANITARY PERMIT# 495-97 —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^1<1 NO PROPERTY OWNER PROPERTY LOCATION �p e 7- d 5.1(.,J '146'6) '/4, S TAO, N, R E (OrK�V PROPERTY OWNER'S MAIL G ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME CITY,STATE ZIP CODE PHONE NUMBER Iff CITY NEAREST ROAD,LAKE OR LANDMARK . ax _ VILLAGE:TOWN OF� zi II. TYPE OF BUILDING OR USE SERVED: -/M 0 1d Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): 111. PURPOSE OF APPLICATION: (Check only one in##1. Check¢#2,3 or 4,if applicable) 1. a. ® 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. to 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. ❑Seepage Trench c. ❑ See a 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): Y Al 2 Private ❑Joint Public Feet VI. TANK CAPACITY Site in allons Total ##of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Se tic Tank or Holding Tank ❑ Lift Pump Tank/Siphon 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 Stamps) 69A P R S W No.: Business Phone Number: l�� lumber's Addr ss(Street,City,State,Zip Code): Name of Designer: 3 ate' L✓ r VIII. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST# j CST's ADE1911ESSWtreet,City,State,Zip Code) Phone Number: c ,� S'�. e 3 G o IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved itary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) Approved ❑ Owner Given Initial cr�'1 Sq�chha^argge�e Fee q Adverse Determination /NV. `}�ou•W -J7 ,607 ` X. COMMENTS/REASONS FOR DISAPPROVAL: BD-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 .Brett and Mary Bader Location of Property SW SW 149 Section 26 T 30N N-R 19 W except the E.E.26 rods of the N. 40 Rods hereof Township St. Joeseph Mailing Address Rt. 2 Hudson, Wisconsin 54016 I Address of Site 132nd Street Hudson, Wisconsin 54016 Subdivision Name None : Lot Number None Previous Owner of Property; Laurence and Anthony Furger Total Size of Parcel 33.5 Acres Date Parcel Was Created Are all corners and lot lines identifiable? x Yes No Is this property being developed for resale (spec house) ? x Yes No Volume _ 54__. and Page Number 57 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 1 (We) ceAti.6y that att statement6 on th.i,6 6ohm cute t ue to the best o6 my (our) knowtedge; that I (we) am (cute) the owner(.a) o6 the phopehty des ch i.bed in thiA .in6o4mat.ion 6o4m, by vihtue o6 a waAAanty deed neconded in the 066.ice o6 the catty Regihteh o6 Deed,6 ass Document No. 334637. , ; and that I (We) phew en tty e phopoded bite 6oh the 6ewaga dL6po.6 .6y.6 em (oh I (we) have obtained an ent, to )tun with the above de d ch ibed phopen ty, 6oh the con6tn.ucti.on o6 chid and the .name ha6 been duty neconded in the 066.ice o6 the County Regi,6teh o6 ad Document No. ;T ) • _ OIL OWNER SIGNATURE OF 0-OWNER (IF APPLICABLE) er 26,1 987 October 26,1987 IGNED DATE SIGNED �,,�,, � ,!~~'-"""'�_�i►._#msµ �� Iva!►s�M+gwrr:wan Nr a.atwllrM C` x of `� lid) : dw -s ) T � . �Istett Net7► tom? pN t .North ; zoom �s..to" ram tilt 4A rt. �tsa� caw�Ey• as,a ssa SO +�o:a of x y_ ,� rnrM�aw Mwrwnl�M�+MIMMAaf M MMr _ iltrata.t!• and•P red" 3 NNI bra•wd+Ir�� .+1 rw�upr►rrnrra al1+�/� i ��1M1!/Mt Alm•M�a�/MNr M f" aqae *Am 10 Poulos" fllr O4 v jp _w T u f•• MwwA+t itaN 1Y •!��_ Ms, �Mfll vill. AMMn►IM� tlndrt w. ^ice rbn of&" CIV Crwtf bp out" Fu1`�w i�ad AnthatW rfi.rrai rtrd th, Ir,n ant pwatm oil W/ Q1pl ' �tp/di lf0 H a STC - 105 r a H SEPTIC TANK MAINTENANCE AGREEMENT o St . Croix County z d a OWNER/BUYER Brett & Mary Bader Husband & Wife ROUTE/BOX NUMBER gt. 2 Fire Number CITY/STATE Hdl.w 1- zip 54016 PROPERTY LOCATION : SW 1& SW 1 Section 26 , T3OON N , R 19 W, ce expt t e . rods of the R:�O row Werof Town of St. Joseph, Hudson St . Croix County , Subdivision Lot 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 put into ` the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system . St . Croix County residents 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- 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 F I/WE, the undersigned,, have read the above requirements and agree to maintain the private sewage disposal system in accordance with x N the standards set forth , herein , as set by the Wisconsin Depart- u 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 . SICNED DATE October 26,1987 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 . DE;'14RTM NT OF REPORT ON L WRINGS AND SAFETY&BUILDINGS DIVISION INDUSTRY, LA WR ANb L PERCOLATION TESTS (115) ;, t= MADISON,WI 53707 HUMAN OELATIONS 0witm Chapter 146,045) 0-- - HI UNICIPALITY: NO.: SU DI NAME: y 5 SECTION:/ 24 /T 30 N11 19 S,- JosePw _ COUNTY: r iS�eg 4 M4Q v 2ys�^r W I S9 0►� DATES fI1SERVATION�S MADE Q Residence Never ❑Rsplece �T 3 /97$ COEXT1174 5N /7�7 uN� ► So t Ls v- 44L�' Z 'So►i_s- q o - A>vs-r c,o RATING:S•Site wiU6W far s""m U•Site weadtaih for 6' I LD j:rECOMMENDED SYSTEM:(optional) Si U S ❑� S ❑1 S g ❑S Cowv IO If Percolation Tests are NOT required D T£: If any portion of the tested area is in the under e.M63.(16915}(b4,indicate: � �'c b S s Floodplain,indicate Floodplain elevation: r PROFILE DESCRIPTIONS i3 -- GROUNDW 0RING ELEVATION A CHARACTER W L TEXTURE,AND DEPTM NUMBER BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) Tq,� 7 3 rs�&cTS v-Ray L A`kk, V49 Ad" gety C- Al -t4e- - 2 711 9Z.4% -it >7.11 /CELLM 2z"$aeN 10 1t""R 3�"8wtM-GS ttSeC . 6,G7 92.41 t4o r4 k� 6,6 13" cr-- 'Z"x:A2 16" $QNMs 3S�B+eN��fhs G I- /2" A8641"s ZlnlQQN�' GR B-Q $:�3 9110.10 Nofv > 83 3c" Ba Ih S R B- P3.68 crzA No-Nv 6ft s''gar�csbC�it q ''6eNrnS �GiP B- PERCOLATION TESTS DEPTH ,TEST N LO IRATE MINUTES NUBR INCHES A TER I I PER INH p. 1 3,9 7 93.12 Z6 13/4 P- P- Z -T--71 NO 10 ir- P. P- E L C t( i6l.i T C Q PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable wit areas. Indicate sale or distances. Describe what an the hori- sontol artd 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, M,Z STELA ELEVATION g9,zQ a j G WT AVfu Li L pf Rrt,� (If Ci .. _ �tr►1`. I� z t a '� � l PP � � �'� 331% c�� ��,�►., 1 � , I • t it s 2 c. J401 C e , ��>rr 1 1' 4 1•��Z f0 � � 46' C�4r 5�' i i( Q x. �' • IL i l � �i a.- � • Rey.. . A 1,the undersigned,hereby certify that the soil tests reported ce 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 we correct to the best of my knowledge end belief. ,NAME print : \ —T-EIrS WERFCOMPLETFD N: 4 /9<67 'ADDRS-'�-- CERTIFICATION NUMBER: IPHONE N optional): X07 `Jccxv :�_ ``T /�v' S�,U a S�iGti► �56G: �+OFsC) CST 51 A URE: DISTRIBUTION:069inal anu one cupy to Local AuthoritY,Property Owner and Soil Tester. I)ILMR-SR"395 (4,02182) —OVER —