HomeMy WebLinkAbout030-1086-60-000 -0 0
C Ol, a) O
O
O� Oq >
a
0. O
n
O
O I
N I
N
tl
.q
� N I
y0
Co
l N
t
6 M
C _
1L C0
Q C
> z N
_rn z C
° I' am
M H fn
O
O z d c
0 z dt c 0
to F- r m 0 z
C E '0
m
Q
N
c0
•Pali a
O M
O N Q
z c0 z o
N z
f6
N C O
y — C
C
N£ �
0 N l6
f6
L ..
d
fl Y
)e
C:N N d L O
c" G D d
vv) tnN _E
co
'n ° U) o
a s a z
•IV R , N
}� 0 rn 00 Z
v = mo
W N O 0 O
O O E M
[b
2
U N Q Z ,", Q
0 O m
O N N
O O
N C
0
y E
o H c
rn a) L) w o o
Y a o 0
O C N -
0 m t
L O a C (n C
O a0 - a) O = a) N °�
4.r o '0 ur a) Z .o
►�.I O M NLo a) j Z' E
• O M fn ''.. fn W O 0 Fes-
a
(n
O �
v a6
✓a d d
a a
• c� a
rr.�,v +, E L c c
`�1 A v a O N v
- 1
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
LABOR'&-HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O.BOX 796 BUREAU OF PLUMBING
MAIIIISON,WI 53707
SW,14,NW1-4,S30,T30N—R19W 21 CONVENTIONAL ❑ALTERNATIVE StateSlanI.D.Number:
Town of St. Joseph ❑Holding Tank ❑In-Ground Pressure El Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Ken Swenson Rt. 1, Box 158, Star Prairie, WI 54026 c�7 '30
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.:
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
William Schumaker i6382 St. Croix 92517
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
DYES ONO ❑YES ONO
BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING:(VENT TO FRESH
ALARM FEET FROM LINE: AIR INLET
DYES ❑NO
OYES ❑NO INEAREST-
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
]YES ❑NO DYES ONO DYES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) DYES 1-1 NO NEAREST
SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDT : LENGTH' NO.OF DISTR.PIPE SPACING: COVER INSIDE CIA. &PITS LIQUID
BED/TRENCH TRENCHES MATERIAL: PIT DEPTH
DIMENSIONS a,
GRAVEL DEPTH FILL DEPTH UISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF PROPERTY WELL. BUILDING'. V NT TO FRESH
BELOW PIPES: ABOVE COVER'. ELEV.INLET ELEV.END: PIPES: FEET FROM LINE: - AIR INLET.
NEAREST--►
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVfDt 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 TEXTURE PERMANENT MARKERS OBSERVATION WELLS
❑YES 1:1 NO DYES El NO
DEPTH OVER TRENCH/BED JD.IEE PTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED SEEDED MULCHED
CENTER. ES'. DYES 1:1 NO
[:]YES ❑NO DYES ONO
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. NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING
ELEVATION AND
ELEV.: ELEV.: DIA.. ELEV.: PIPES DA:
DISTRIBUTION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
INFORMATION PLANS.
❑YES NO ❑YES ONO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
(]YES ❑N• YES FEET FROM LINE:
F ❑ ❑NO NEAREST
a
o
Sketch System on ( RtapiEnty file for audit.
Reverse Side.
SIGNATURE TITLE:
DILHR SBD 6710(R.01/82) 1 G� / Zoning Administrator
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT
APPLICATION
e
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 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:
!. Property 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'/z 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;
Y 9 ) ,
P
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)64ter
included the creation of surcharges (fees) for a number of regulated practices which ih'iscorin`s
car, effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasure'
i s u s ed in your building is retu rn ed to th e groundwater thro ug h you r soil
absorption
0
system or the disposal site used by your holding tank pumper.
o
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-
\.&.ate , groundwater contamination investigations and establishment of standards groundwater, _
worth protecting.
:'BD4398;8.03/86)
7
SANITARY PERMIT APPLICATION Coy X
� DILHFi In accord with ILHR 83.05,Wis. Adm.Code
STATE SANITARY PERMIT#
—Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER
8%x 11 inches in size. 1792:57
—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
514)% V J/4, S TSd N, R / E (o W P OPERTY OWNER'S MAILING ADDRESS LOT NUMB BLOCK NUMBER SUBDIVISION NAME
CITY,STATE ZIP COD PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK
,, ek 4 9,01,3 E]1 X TOWN OR VILLAGE: S Ali
II. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify):
III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable)
1. a. �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. XConventional b. ❑Alternative C. ❑ Experimental
2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP
In-Fill Tan k
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. t9 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): nn
�} o' Feet JC 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 strutted
Septic Tank or Holding Tank ! ❑
Lift Pump Tank/Siphon Chamber ❑ I ❑ 1 ❑ ❑ ❑
VII. RESPONSIBILITY STATEMENT
I,the undersigned,assume responsibility for installation of the private sewage system ho An on the attached plans.
Plumber's Name(Print): Plumber's Signature:(No Stamps) QOMPRSW No.: Business Phone Number:
,,,Z
Plumber's Address(Street,City,State,Zip Code): Name of Designer:
VIII. SOIL TEST INFORMATION
Certi 0 Soil Tester(C ) e CST#
;?;Z 7
CST's AD ESS(Street,City,State,Zip Code) Phone Number:
9-r' -.,-/ _TX ,Yje ga= X-ei.1 l S N ?a d
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved S.nitary Permit Fee Groundwater ate Iss g Agent Si t e o Stamps)
XApproved E-1 owner Given Initial charge Fee ^
Adverse Determination
X. COMMENTS/REASONS 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 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 N's k°e 5��• Vii r, (� S�!c�s u
Location of Property S U3 1% N W 14, Section 2y , T 3y N I�' W
Township _ �"� lly Sept
1
Mailing Address LJ i SL
Address of Site
5
Subdivision Name
Lot Number N1
Previous Owner of property
Total Size of Parcel d ctC- e S
Date Parcel was Created
Are all corners and lot lines identifiable? S _ Yes No
Is this property being developed for resale (spec house) ? Yes _�_ No
Volume and Page Number 39I 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) eeAti6y that att Statements on this 6onm ane tAue to the best o6 my (ouh)
know.tedge; that I (we) am (ahe) the owner(S) o6 the phopehty deS ehibed in th.i.a
.in6onmation 6onm, by ViAtue o6 a wa Aant deed recorded in the 066.ice 06 the
County RegiateA o6 DeedS aS Document No. ,3 ; and that I (We) pne6entfy
own the pnopoaed z to bon the sewage dispoS Sys 'em (on I (we) have obtained an
easement, to nun with the above de cAibed pnopehty, bon the eonSthuction o6 said
ayatern, and the same ha.a been duty recorded in the 066.ice o6 the County Reg-iaten o6
Veeda, ae Ooeament No. ) ,
SIGNATURE OIL OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
DOCUMENT NO.
' WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA
STATE BAR OF'WISCONSIN FORM 2-19821!
V�PC;GEt���
EUGENE WALTERS AND 'PATRICIA A. WALTERS FKA PATRICIA A. r EGISTERS OFFICE
--....a......a-----:---
BROWN, husband and wife •-----_. 5T. CROIX CO., WIS.
Recd. for Record this 13th
If
------------- ----------------------------------------------------------- ------•----------•-•---•-------- May
conveys and warrants to KENNETH A. � Y of --
A D 986 j
SWENSON AND _LORI- A. _SWENSON� ai 11 :20 A
husband and wide
ij
---...-•---••.............................•-..---•---------.......... �I is !1
---------------:............
....--•--- ----- aZ��rtDi�ilr
.. ...... --------------------------------------------.._.. .....__._-_....._._ 7 RETURN TO REALTY WORLD .t
.........--•-•- --••-------------------•------.-•-•-- 1 221 E.
Chestnut
the following described real estate in ..._... ;;Stillwater, MN 55082
St Ere-i ............... County,
State of Wisconsin: -
Part of the Southwest
Quarter of the Northwest Quarter of Tax Parcel No_ ____ ___________________
Section 30, Township 30 North, Range 19 West, described as follows: Commencing at the
Southwest corner of the Northwest Quarter of said Section 30; thence East along the
South line thereof 548 feet to the Southwest corner of parcel conveyed to Leonard
Youngquist and wife by deed recorded in the office of the Register of Deeds for St.
Croix County, Wisconsin, in Volume 397, page 181, document 273552; thence North 50
feet to the North right of way line of County Highway E; thence continuing North 423
feet; thence West i�
parallel to the North line of County Highway E 548 feet to the West
line of the Northwest Quarter of said Section 30; thence South along said line
li
to the PLACE OF BEGINNING. Containing 6.14 acres including highway. 473 feet;
Yi
I�
ITANSFM
I� E
$ 51:00 3
FEE
if!
is not
This. - ................. homestead property. I t
( (is not) `
Exception to warranties:
Dated this 9 j
............................................ day of ...May
......... ------ , 19..86....
I
I
-------------------------....----.-----....._.._.-__.- ...-------(SEAL)
Eu
tiJalte --------(SEAL
'
........................................ '0 }
�--/
•-- •-•--------------------- ----------(SEAL)
P icier . ,Waite s, fka atricia-a. Brown
* ....-------•.............•----..._.. •----•------.--••-
AUTHENTICATION
ACKNOWLEDGMENT
Signature(s) -::
---•----•-- STATE OFXW_jg002Z Minneso a
ss.
Wash---------------ington County.
authenticated this _______•day of__________________ i
19____-_ Personally carne before me this
9 ....day of
May --------- 13S�t.... the above named 1
III Eugene•_Wal_te-rend Pat> i�ia_.A.-.-Walters,.- fka
Patricia_A....Brown,--.husbaiRd..and. wife....-•---
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not ...............•-•------..-........-•------......----.------------------........
authorized by § 706.06, Wis. Stats.)
to me known to be the person 5.......... who executed the
THIS INSTRUMENT WAS DRAFTED BY foregoing instrument and acknowledge the same.
REEILTX WORLD Paulex & Johnson t Inc,
u21 E. Chestnut, Stillwater, MN 55082 '
..........................................................................
merry-i�lcitbnaughep-....•..................................... Notary ublic ........W h•
(Signatures may be authenticated or acknowledged. Both y �� 7I1fl QB•••.••..•••• County,)WAL MN
are not necessary.) MY Commission is permanent.(if not, state expiration
date: ...June..17............. .............1 19....9.1.)
*Names of .AAA AAAAAAAAAAA IAAAAAAA/AAAAAAAAAAAA■
Persons sicning in any capacity should be typed or printed below their eignatufes, 4a
TERRY C. McCONALIGHEY
NOTARY PUBLIC-MINNESOTA
HCIMiIIarCompWV STATE BAR OF WISCONSIN WASHINGTON COUNTY
YY1..uMN,WI,aM,M NORM No. $-_ 1982 My Comm,Expires Juna 9101W4• 13002 .
is VWVWVVVVVVVVVVVV�VVV aI WVL
cn
H
- a
ST C - 105 r
a
y
SEPTIC TANK MAINTENANCE AGREEMENT o
St . Croix County z
d
a
OWNER/BUYER ��' SUJP_ U.,
ROUTE/BOX NUMBER 01 Fire Number
CITY/STATE b4 , YOSC_ ph ZIP �� 0
PROPERTY LOCATION : 'SW 14, NLJ 14, Section 10 , T 30 N ,
Town of S� �el e' , St . Croix County ,
Subdivision , 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 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
H
the standards set forth , herein , as set by the Wisconsin Depart- ro
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
D A'r E Z ly-
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 .
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
INDUSTRY, REPORT
LABOR AND PERCOLATION. TESTS (115) P.O. BOX 7969
-IUMAN PELATIONS l / MADISON,WI 53707
(1-163.090)& Chapter 145.045)
LOCATION: TON: TOtNNSHIP/ ITY: OT NO.:BLK.NO.: SUBDIVISION NAME:
COU TYhh OWNER' B 'YER' NAME: M LIN AD R SS: .9
J_S_E DATES OBSERVATIONS MADE
NO.HcDRMS.: COMM R D S R TION: R S: PERCOLATION TESTS:
Residence ,) &New ❑ReP!ace
T
RATING:S-Site suitable for system U-Site unsuitable for system
-ONVENTT AL: MOUND: IN-GROUND-PRESSURE: S STEM-IN-FILL HOLDING TANK:RECOMMENDED SYSTEM:(optional)
ES ou cgs ou TA au a S 9u EIS IZU I e
If Percolation Tests ata NOT required DESIGN RATE: If any portion of the tested area is in the
under s.1-163.09(5)(b),indicate: /n i7 f I Floodplain,indicate Floodplain elevation:
/!
PROFILE DESCRIPTIONS r �b
BORING TOTAL— DEPTH TO GROU NDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH
NUMBER PM'V-j ELEVATION OBSERVED .HIGWE—ST TO BEDROCK IF OBSERVED ISEE ABBRV.ON BACK.)
yz q z �� 9v ,7 -
B- 1 OAk to ,.s,,c. 3 �.� .d .,��.. ,c3r�.ssa► �. ,�,
Sd o ) Sy .b . 3� a s 3-0 e 12 13- A30 An
s.L X0
B- .3 ' T�' NS.J /
�o / /l1 ,L •S. ,1 .�.S.,C. S..0 Aii
n ,C. O
g3 17 00
B-
eaga _7
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME D qP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING !NTERVAL-MIN. P A1052 PER100 3 PER INCH
P
P-
P
P.
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•
ontal 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
f Ian:+slope.
SYSTEM ELEVATION
9 0�
AN
r
#13,p
t
°�
A.
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
\dministrative Code,and that the data re•:orded and the location of the tests are correct to the best of my knowledge and belief.
DAME(print TESTS WERE COMPLETED ON:
\DDRES : �/r CERTIFICATION UMBER: PHONE NUMBER(optional):
A&Y 10 CST SIGNAT E:
)ISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester.
)ILHR-SBD-6395(R.02/82) —OVER —
S �. S �✓� S'� c 30
� � w
ee
woo
duo ,
k3
0 G,