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CROIX COUNTY, WISCONSIN. 3z6 l7eL ua�odi S94 ccP-c lcic ..T� SUBDIVISION LOT LOT SIZE s g �•°�cs PLAN VIEW Distances and dimensions to meet requirements of H63 SHO lnl_...EVERYTHING WITHIN 100 FEET OF SYSTE14 - - Z r -- — -- -- - ,. r t • Z Irldica te North A row Ffl i SCALE.• BENCHMARK: (Permanent reference Point) Describe: To, TeCe pq-4 Elevation of vertical reference point : Slope at site : 45% SEPTIC TANK: Manufacturer: Liquid Capacity: Number of rings on cover : Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: PUMP CHAMBER Manufacturer: Number of gallons Number of gal . pump set for a cyc e gallons ; total capacity o distribution lines gallon: size of pump head; gallon per minute horsepower brand name of pump and model number ; Type of warning device HOLDING TANK: Manufacturer Number of gallons Elevation of manhole cover Type of warning device SEEPAGE PIT SIZE: Number ot pits teet diameter feet liquid depth seepage pit in epe-elevation bottom of seepage pit elevation feet . SEEPAGE BED SIZE: number of lines �4 width y ' length L-4/ the depth ay SEEPAGE TRENCH: width length PERCOLATION RATE AREA REQUIRED 63oO AREA AS BUILT---- ,u •....._._ INSPECTO - DATED PLUMBER N JOB LICENSE NUMBER DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR,&HUMAN RELATIONS � j P.O.BOX 7964 PRIVATE SEWAGE SYSTEMS 2 DIVISION "J `MADISON,WI 53707 BUREAU OF PLUMBING C9 CONVENTIONAL '❑ALTERNATIVE ^ `,e State Plan I.D.NU r: (it assigned) ❑Holding Tank ❑In-Ground Pressure ❑Mound al NA OF PERMIT HOLDER: ADDRESS OF PE IT HOL ER: INSPECTI N AT I I rin��in pnj r;al _Q BENCH MAR ermanent reference point)DESCRIB D FFEREN FROM PLAN: REF.PT.ELEV: CST REF,PT.ELEV.: S qv Ne a of lumber. P/MPRSW No.: Coumy: nibry Perm it Number: SEPTIC TANK/HOLDING TANK: y MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV: WARNING LOCKING COVER 'f S P OV ED: PROVIDED: ('�'") ` YES ONO ❑YES ❑NO BEDDING: VENT DIA.: VENT MATL.: HIGH NUMBER OF R AD: ROPERTY WELL: BUILDING: V NT TO FRESH (t /) AL❑M. FEET FROM _I LINE: y AIR INLET: ❑YES ❑NO /`r/ NO NEAREST DOSING CHAMBER: MANUFACTURER: BEDDING: LIOUID AP MP MODEL. PUMP/SIPHON MANUFACTURER: WARNING LABEL JLOCKINGCOVER PROVIDED: PROVIDED: DYES ❑YES ❑NO ❑YES ❑NO. GALLONS PER CYCLE: PUM AN C N L OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT FRESR (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF) DYES El NO NEAREST SOIL ABSORPTION SYSTE .Ch the soil nVbisture at the depth of plowing LENGTH IAMETER IMATERIAL AND MARKING or excavation. (If soil can be rolls into a wire,construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: BED/TRENCH WIDTH. LENGTH: NO.0 DISTR.PIPE SPACING: INSIDE IA; LIQUID On[ TRENCHES , MATERIAL' PIT DEPTH. DIMENSIONS L T FILL DEPT UIS R I F DISTR. IRE IS I A IAL: NO.DISTR. BE OF - WELL: BUILDING: V NT TO FRESH BELOW PIPES: ABOVE COVER: ELEV.INLET EL END. PIPES LIN ,! FEET FROM Jh Al R INLET: NEAREST U1 lJ MOUND SYSTEM: Mound site plowed perpendicular to sloe O Check a texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mo d-`systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- ❑YES N ets the ria for medium sand. TIONS MEASURED. ❑ OIL COVER TEXTURE PERMANENT MARK Rs: OBSERVATION WELLS. lr l YES 1-1 NO OYES NO DEPTH OVER TRENCH/BED DEPTH OVE N / D H OFT SOIL: SODDED: SEEDED MULCHED: CENTER: EDGES: ❑YES ❑NO 1:1 YES ❑NO ❑YES El NO PRESSURIZED DISTRIBUTIO SYSTE . BED/TRENCH WIDTH LENGTH. NO.OF LA ERAL r SPA , GRAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PU MANIFOLD DISTR.P E OL AL IN-0.DISTR UI DI THI UrION IRE MATERIAL a MARKING ELEV. ELEV. MA ELEV.. PIPES DIA.: ELEVATION AND DISTRIBUTION INFORMATION HOLE—SIZE; HOLE SPACING OH IL O REC7 COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED F PLANS i XEJNO ❑YES ❑NO COMMENTS: ERMAN N A 7VATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: DYES NO DYES ONO NEAREST 00 °. Sketch S�tern on 1 Reverse Side. /� l0 Retain i ounty file for audit. SIGNATU"E. / DILHR SBD 6710(R.01/82) DEPARTMENT OF APPLICATION . INDUSTRY; FOR SANITARY SAFETY&BUILDINGS DIVISION LABOR AND PERMIT P.O. BOX 7969 HUMAN RELATIONS (PLB 67) MADISON,WI 53707 Attach plans for the system on paper not less than 8'/2 x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed,sealed and dated by the designer. If designed by a Master Plumber,the date,signature and license number must be shown. The owners copy or a legible reproduction of the soil test report must be included. Property Owner: Mailing Address: &vqm b¢, 5 Property Lo tion: City,Village or i County: s t/a sw'/aS I /T-:ii N/R 1 S E (or)* S0., ,e.- e- T ST Lot Number: Blk No.: Subdivision Name: Pizm ,Lake or Landmark: State Plan I.D.Number: f V �< �� (If assigned) & TYPE OF BUILDING Number of ❑ Public* ❑ Variance* ❑ Other (specify)* �J_ /�. Q, —Alf/—�/D Q�' Bedrooms: 51.1 or 2 Family *State Approval Required. a TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER Jy MANUFACTURER: v , (�r , EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED(Square feet): Pig-New ❑ Replacement ❑ Experimental 2-Seepage Bed ❑ Seepage Pit ", ❑ Alternative (specify) ❑ Seepage Trench Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): Q Private ❑ Joint ❑ Public I,the undersigned,hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber: Sign tur MPRSW No.: Phone Number: Plumber's Address: Name of Designer: WaCL< C C_ w 'C COUNTY/DEPARTMENT USE ONLY Sign ture of Issuing Age f Fee: Date: 11 p ® APPROVED Sanitary Permit Number: ❑ DISAPPROVED Reason for Disapproval: Alternate course(s)of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White-County,Canary-Bureau of Plumbing, Pink-Owner,Goldenrod-Plumber DILHRSBD-6398(N.03/81) � A r INSTRUCTIONS FOR COMPLETING FORM 115 - SR® - 6395 To be a complete and accurate soil test,your report must include: 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 3, MAXIMUM number of bedrooms or commercial use planned; 4, Is tEsis a news, or replacement systern; b, Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 3, PLEASE use the abbreviations shown here for writing profile descript ions and convicting the plot plan; 1, MAKE A LEGIBLE diagram accurately lcacatin7j your test locations. Dravving to scale is preferred. A Si';a,irate sheet may bey used if desired; S, Mal;e sure yOur benchn;ark and vertical elevation reference point are CIcarly shown,Said ace Pei manent; 3. Cc,,nplet-e all Supt«per rate boxes as to dates, names,addresses, flood plain data, percolation t€ast exernl'>- timl if appropriate; 10. If _he information (such as flood plain,elevation) does riot apply, place N.A,in the apf)rohriate box; if. Sign the form and Mace your current address and your certification number; 12, iv1 r<e legii_ale coPiea, and distribute as requlred. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION, AE I1EVIATI DNS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st _ r;wnw io"cxr 10") BR Bedrock ra - f G-ta, ic. i3 10"I SS — Sandstone gr Gr€avel (cinder 3") LS — LJmestono s — Sand HG1iv High Gmuodkivater rs Coal-,,e `Said P�(r t `t r oiat.n,n Rate rrw(l s ._ medium Sand VV __ °,,!t s f mo Sand f}dq 3 id nos is — Loam, Sand Greater Than l Sand, Loam Less 1'raa3, =t _ Loam Brl - Brown Silr Loy mi Rl Bl aCk Sill G y Cir<; 'c? — Clay Lean) y - yello"%' sra's .sandy Cl<ry Lc}arn R Red src;l Silty Clay Loam mat. -- Vic,tt`=.es se -- Sandy Clay r.s, ,, r.,. ;rCa — Silty CPIa� fif _ ,a_av, llna, faint C l«,� ;c; _ rara,morr,coarse el= - P'uat rnm — la:laaay, medium nl -- Muck d - distinct p -- prominernt HVVL — High vvattar level, Six general soil textures surfacir mater for liquid vvaste disposal BM Bench Mark VRP - Vertical Reference Point TO THE OWNER: This soil test report is the first step ire set°urinc,a sanitary permit,The county or the Department may reoUest verification of this soil test ill the field prior to pert-nil.. issuance. A complete set of plans for the private sevvage system and a permit application must be submitted to the appropriate local authority in order to obtain a pernnit. The sanitary permit must be obtained and pasted prior to the start of any construction. DEPARTMENT T OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUS DIVISION HUMAN AND N RELATIONS PERCOLATION TESTS (115) MADISON WI 7969 ' HUMAN (H 3.09(1)&Chapter 145.045) LOCATION: SECTION: OWNS /MUNICIPALITY: OT NO.:1 tL BLK.NO.: SUBDIVISION NAME: s 4/ %/sip'a /T� N/R' �E (or,(W �r, .,. " `� t7 1J4 CO�yU�-NTY: OWNER'S} BUYER'S NAME: MAILING ADDRESS: USE ,G F, �� � ��. �� c: t.J r�s ' . DATES OBSERVATIONS MADE NO.BEDRMS,: COMMER IAL DESCRIPT e PROFILE DESCRIPTION OLATI N TEST® sidence e XNew ❑Replac1 42 j Ili RATING:S=Site suitable for system U=Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND PRESSURE: SYSTEM-IN-FILL HOLDING TANK:RECOMMENDED SYSTEM:(optional) DS ❑U 91 S ❑U ©S ❑U ❑S ®U ❑S ®U ed [ufn,:m.'H6'3 Pcoaton Tests are NOT required DESIGN RATE: FF any portion of the tested area is in the .09(5)(b),indicate: oo dplain,indicate Floodplain elevation: hj PROFILE DESCRIPTIONS BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH NUMBER DEPTH IN, OBSERVED EST. I HEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) s[ ' `/S�Q SC w rkSL /yied S (} G > T /O�"p L. S L 7 v" A, Q'L Dc1 r/c SL. (SG..J • 7 t/"Q M/C -B- 3 Nit `•78.60 r„0,,e 7 �y ((xPP-0x. "rx%c/rj H B- q' I `j i6.oF� Q77-4,�/e) c �/o" . -S �. s c 3 v as, /he s B- VY L y.2'(ih 4C G✓�la. s 3J /he d S PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCH 5S RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. P R_ IOD 1 PERIOD 2 PER D PER INCH P O oL �� a P- NG eti 'J'/ .3,7/11 3 !� 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 ELEVATION 9 6 -_ Qr l �. Te ea(. t (00.33 E I3 $ ,` L?c U, ' . x Ace r"eSTr E 77 _._ .6 may ; r -71 a14lnhh►�f. ' t2 y0o Ai o i i t t 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 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: ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional): R`t Q ox 66 CST SIGNATURE: I DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. 1_HR-SBD-6395 (R.02/82) —OVER— T � i J J 1 ti .o U _45 ca J ry v .vim S m. � o t1 i 'o 3' v � I r N � s 3 Cz M a r C Ci 3 J 3 { 1J1 ✓1 (� b Lam' Q c,_1 c » . , . . ¥ 4 �\ . ! \ � \ 7 lotu � \ A � w \ ) \ f \ \ a . � } ` o { � ƒ � 4 & & ¥ � � ] \ y p � / ¥ 0� ST. CROIX COUNTY CERTIFIED SURVEY MAP LOCATED IN PART OF THE W 1/2 OF THE SW 1/4 OF THE SW 1/4 OF SECTION I, T 31 N, R 19 W, TOWN OF SOMERSET, ST CROIX COUNTY, WISCONSIN. N W 114 CORNER OF SECT/ON 1-31-19 OWNER 8 PLATTER COUNTY MCYVUMENT MARVIN VIEBROCK BOX 187 P/PE LIES ON E-W FENCE LINE Q OSCEOLA, WISCONSIN 54020 3.5'EAST OF N-S FENCE LINE PIPE L IES /0.5' SOUTH OF FENCE L/NE -U&PLATTEp-I-,4NQS S. 880 46' 36" E. 660.77' THE NCIRTH L/NE CIF" THE SW 114 - SW 1/4 O SECT/ON / W E LOT 2 S Uk OD 591,621 SO. FT (13.582 ACRES ) D Z INCLUDING RIGHT-OF-WAY y SCALE ONE INCH 15 FEET O 581,643 SO. FT. (13.353 ACRES) 100' 50' 0 100' 200' x EXCLUDING RIGHT-OF-WAY (-Z N H 0 ,D N r y IC u C oo 1 m \ % LEGEND w ur ro .o 890 01' 54" E. 290.- iy 0 1"X 24" IRON PIPE SET y WEIGHING 1.68 LBS-/LIN. FT. / • 1" IRON PIPE FOUND * 0 FENCE LINE THE WEST LINE OF THE SW 1/4 A OF SECTION 1-31-19 IS i ASSUMED TO BEAR NORTH. N. 890 01' 54" W ( Z LOT N y ONYHAGEN i�150.00' ° p cj j>�217,768 SO. FT. p ,.N (4.999 ACRES)O INCLUDING RIGHT-OF-WAY y � �'204,717 S0. FT. ` 1� w ( 4.700 ACRES) 00 w pfd N p S U RJ o'k = V A = EXCLUDING RIGHT-OF-WAY r �� �IV O m f SIGNED C (� m O i ALLEN C. NYHAGEN R. L. S. 1407 O DATED I B�diTi COUNTY TRUNK HIGHWAY N. 89° 01' 4" W. 511.71 45' 221.71'—'— -- -- - -)- 00' �...., S //4 CORNER OF SECT/ON /-31-11 'R/W -INC 1r AOL) COUNTY MONUMENT 4 221.74 290.00' 5'W C R OF SECT/0'1( /- /-/9 N. 89° 01' 54" W. 511.74' Sw COUNTY NOIVAMEN)- THE SOUTH LINE OF THE SW 114 OF SECT/ON / n VOLUME,, PAGE Jd S�0/2- CERTIFIED SURVEY MAPS this ln#lr4m6nt was drafted by ken hodkiewler. J08- No 22-.gg ST CROIX COUNTY, WISCONSIN. . PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Ma facturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufact/re Alarm Switch Type: Number of feet rest pro rty line: Front, O Side, O Rear,0 Ft.of feet fro well: Number of feet from build g: (Include distances on plot plan). I SOIL ABSORPTION SYSTEM I Bed: Trench: Width: /? Length: 8'.3'. Number of Lines: Z Area Built: 29 64P I Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, O Rear,®Ft . S-0 Number of feet from well: 7�Q Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number of pits Diameter: Liquid depth: Bott of seepage pit elevation: Area Built: Has either a drop box O or di ribution box O been used on any of the above soil absorbtion sytems? (Check one . HOLDING TANK Manufacturer: Capacity: Number of rings used: Elev ion of bottom of tank: Elevation of inlet: Number of feet from nearest pr rty line: Front, O Side, O Rear, 0Ft. Number of a from well: Number of f t fro building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Y ,.20.4-2 Plumber on job: /it4��!:�F 'r. f License Number: 3/84:mj Form - STC - 104 t +r AS BUILT SANITARY SYSTEM REPORT OWNER � �����nd�,�uGz TOWNSHIP Sot-.Qrtt'� SEC. �_ T 3l N-R 1`3 W ADDRESS R 2 fop)( ) SZI-p ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT 1 LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of IIHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM N ' LTA d To*o le 1 r rl r �i 1 I Shs• 1 ( � ko w.e `L D 4Jttl V 7 00, 40 t 1 � — or•� v!4JQ� .S aj J', To�' INDICATE NORTH ARROW r. BENCHMARK: Describe the vertical reference point used Ta a TeL� �1 Elevation of vertical reference point: /Op Proposed slope at site: �x , r;h SEPTIC TANK: Manu ac t ure Liquid Capacity: Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road.: Front 10 Side Rear, O feet From nearest property line - Front 10 Side 10 Rear,0 feet Number of feet from: well building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE cn ,� p r chi �6 Z4 '6 n— U1 a\ 1 N Z l zoo ^ I I r I s t O SS r Oy CV 3 rj- M v �' ,D�"-�vP C✓G 3T � a s t DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION ...R,O.8><iX 7969 BUREAU OF PLUMBING MADISON,WI 5370T SW-14, DWI 5370 N-R19W El CONVENTIONAL ❑ALTERNATIVE State Plan I.D.Number: (11 assigned) Town of Somerset El Holding Tank El In-Ground Pressure El Mound I. NAME OF PERMIT HOLDER: RESS OF PERMIT HOLDER: INSPECTI D ADD �l. ._( Ri oberto Rodriguez Route 2 B — _ u � J:` 0 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: Michael E. Wilson I6388 St. Croix 92504 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: OYES ONO ❑YES ONO BEDDING: VENT DIA.: VENT MAT L.: HIGH WA NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM LINE: AIR INLET. E YES ❑NO ❑YES ❑NO NEAREST DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY. PUMP MODEL: PUMP/SIPHON MN R. AUFACTURE IWARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ONO DYES ONO ❑YES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING: V (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET: PUMP ON AND OFF) ❑YES ❑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 LEN�{[H/� NO.OF DISTR.PIPE SPACING: COVER JINSIDE DIA. #PITS DEPTH LIQUID BED/TRENCH / LS TRENCHES MATERIAL: PIT DEPTH DIMENSIONS L /l GRAVEL DEPTH FILL DEPTH JUISTR.PIPF DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF PROPERTY WEE 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 PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. DYES ❑NO OIL COVER ITEXTURE PERMANENT MARKERS OBSERVATION WELLS a El ❑NO ❑YES NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED. SEEDED MULCHED CENTER: EDGES: ❑YES El 1:1 YES ONO ❑YES El NO] PRESSURIZED DISTRIBUTION SYSTEM: WIDTH: LENGTH. NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPF. FILL DEPTH ABOVE COVER. BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL. NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING ELEV.. ELEV.: DIA.. ELEV.. PIPES DIA.: ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING: GRILLED CORRECTLY COVER MATERIAL. PLANS CAL LIFT CORRESPONDS TO APPROVED ❑YES 0 N DYES El NO COMMENTS: PERMANENT MARKERS: ll OBSERVATION WELLS: NUMBER OF PROPERTY WELL: JBUILDING: FEET FROM 1:1 YES FIND- OYES 1-1 NO NEAREST r Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE Zoning Administrator DILHR SBD 6710(R.01/82) Thomas C. Nelson 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 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; 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; Vl. 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; 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 included the creation of surcharges (fees) for a number of regulated practices which Wisco in can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried t�s'EStIfB is used in your building is returned to the groundwater through your soil absorption o system or the disposal site used by y�jur holding tank pumper. a The monies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural R;:�sources. These funds are used for monitoring ground- water, groundwater contamination investigations and establishment of standards. Grou-dwater, it's worth protecting. SBD-6398(R.03/86) —' SANITARY PERMIT,APPLIGATION COUNTY T DILHR In accord with ILHR 83.05,Wis.Adm. 'Code S7- Cio ix STATE SANITARY PERMIT# x 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 4r---r No PROPERTY OWNER PROPERTY LOCATION 06e.-T e L .5w %4 S"cw %a, S / T j/ , N, R E (or) PROPERTY OWNER'S MAILING ADDR SS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME 4P 2 d fSy - -41/* <1. .V9- *V/* CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREAKE OR LANDMARK O VILLAGE: S"gg e s&7, j' Al 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. El New b.0-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. i4conventionai 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. ®.See a e 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): 43 G Z 560 `3G Feet 54Private ❑Joint ❑ Public VI. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic A Tanks Tanks structed pp' Septic Tank or Holdin Tank ❑ ❑ Lift Pump Tank/Siphon Chamber ❑ 1 ❑ ❑ ❑ 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). MPRSW No.: Business Phone Number: wi, c4-4.. C 6'. L-10"t •" r. t✓.P.�« 63 PP lit -2 4 t-1S'.?7 Plumber's Address(Street,City,State,Zip Code): Name of Designer: VIII. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST# i l CST's ADDRESS(Street,City,State,Zip Code) Phone Number: lei,-- 0- L-0,; /S- IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater a Issuing Agent Signature(No Stamps) CAA roved 4K Surcharge Fee 9 Approved El Given Initial 7� Adverse Determination U 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 G'-6 � e ZS �� r 11�f Location of Property 5 ll) '14, Sectio , T / N-R 9 W Township cso`y,, e - 06 . !tailing Address W T L -- 4�- 7C /,f-4/ ^ Address of Site Subdivision Name — . Lot Number al-�0 Previous Owner of Property G(12Jd1 � Total Size of Parcel _ Date Parcel was Created Y3 Are all corners and lot lines identifiable? Y Yes No Is this property being developed for resale (spec house) ? Yes )4- No volume . and Page Number S�Z, 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. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTV OWNER CERTIFICATION 1 (We) cexU6y that att statementd on thin onm ane tAue to the but o6 my (oun) know.tedge; that I (we) am (ahe) the owneA(b o6 the pnopeh ty de.a ch i.bed in thiA .i,n6o4mati,on 6onm, by viAtue o6 a waAAanty deed Aeconded in the 066ice o6 the County Reg.i.6.teA o6 Deeds ad Vocument No. 2- Zs ; and that I (We) peed en tey own the pnopoaed bite bon the 6ewage diApozat dya em (on I (we) have obtained an eaaement, to nun with the above deacnibed pnopenty, bon the conatnuction o6 aaid eya.tem, and the name has been duty teemded in the 066ice o6 the County Reg-iaten o6 Veeda, as Vo No. ,3 2-Co l2. I . SIGNA 01 OWNE / SIG TURF OF CO-OWNER IF PLICABLE) !. DATE GNED DA SIGNED l.; . H a ST C - 105 r 9 H SEPTIC TANK MAINTENANCE AGREEMENT o. St . Croix County z d a '` H OWNER/BUYER s C�cv� a/SB Q��r G 2 _ th - a ✓S`, '� � - Fire Number ROUTE/BOX NUMBERl Z U "M l4 C I T Y/S T A T E I P _ PROPERTY LOCATION : W 14, !z, Section T 3/ N , R W, Town of � `-MQ `T' 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 V. I/WE, the undersigned,, have read the above requirements and agree to maintain the pria,yate sewage disposal system in accordance with x H the standards set forth , herein, as set by the Wisconsin Depart- w ment of Natural Resources . Certification form mist be completed and returned to the %St . Croix County Zoning Off. ce within 30 days of the three year expiration date . SIGNED / DATE 1 f� l� St . Croix County Zoning Office P . O. Box 98 ' Hammond , WI 540151 715-796-2235) or 715-425-8363 Sign , date and return to above address . d TPA. UCTIONS FOR COMPLETING FORM 11 5 - SBFJ - 6395 �?, a...-3,i t:�3r� �1,'.is>. ?-£.: di:i_�€ib t::. 4�}E ifr?it, } )t.. ,;:�:i1t'€ 'Y!1<•s. ,.i..?C.€ ` ' 1'he usp s'usI .I a ,y' € -0,ca,..',Jw'-.t er x 'S, i ci r€1's.(tc,%.;;e z.,r CIYMM' .,'ial p. 3. lV1A A N1'tUTV1 €. wnb ! w bl,df'c`?wns or i);ulirlc?fjr , 6s a ')! CisSt:Gin; ;;,,r za.:`t€= o ,. ,u€t<.,f; ty r.tir.c >ox:s. A'61 e U i T i`tBLF f f)i3 A 4 011')1 -0 Ai",,X C)Ni.Y IF AL IS A%PE' RULED OUT BASED 01"N SOH- CONDII IONS; N>"e ;t I ting p-ohlu<e, co r= ti t thv plot Isa€E, . `L s s shova !, c�`,€,l€�. I..,._<.:il3 i...t '€<'.C;€t!rn accu at'..'h i.3.,.;9t€ng y_;tl.' tesi locaticin�s. Dr&,vinq t. cal= i,,, pl to eued, A Mi la,.£, r.: You €3:,?. ,.,.., ?It, tlr,4€i ..et�si on Etferenlc, j)f::€w, a€€', cle€[., names,s,af:l ti rf sse.. j:Cs.,d plain dai:a, p{!St e xeIY p- 10, �f t,t . .T?3i:r,SSa €CJ(1 (s;1ci a," € od olds€ 4„ovation}doo: no? apply, € 1:3 tut agaA in ,h, _t)t- t,tir:.3€t£? boxy , skin `,.he-tot l'% ant: i>{'sw: :j/OUt G(.il",e?ta`.:addi-e:.ss cwt.d YOU., cellifica"S ol-1 nurY;fie.'€'; 12. £U'K e Wct;bic,' cop,£.s and d' tribu'e as ,rs i.€€ieri. ALL SOIL_ 'FE STS (e;h1Si° BE FILED WITH THE l_.0?t',fi L 1 .11 I6C)r ITS'�Q`'v! 19I:�1 30 DAYS OF COMP!-ETIO3N, ABBREVIATIONS FOR CERTIFIED SOIL TE: T EFTS Soil Separr£tes and Textures Other Symbols st — stof,,a over IV) B - Bedrock cob co!)We t.:3- 10", S Sandstone ;t. _- Gravel (under 3") LS Limestone i l ';? t i £'r�� t«, atld €stns.; r L oa'=v r - 10Y 1-0,3571, ln b,trany; f.'f„ --- C.£)rYl r7loni coal se' 1ltfi;i,. it gh vvatei lo vol, 9 surfecC: au,1, fog :,. ..r z a;t ,pos:i i , ... Benchh.lark VFW Esc tical R f 'e r) C}6n,, TO THE OWNER: This soil test report is the first stets in securing a sanitary peti-nit. The r;atarrty or the Department may request verification of ibis soil tr:st in the field prior to rzermit issuance. A complete set of plans For the private sewacle system and a p-r nit appiication must lx! submitted to the approp iau, local al.thority in order to obtain a permit-The sanitary permit rnLJSt be ohtained and posted prior to the of any construction. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS DIVISION INDUSTRY, LABOR AND PERCOLATION TESTS (115) MADISON WI 53707 HUMAN RELATIONS (ILHR 83.09(1) &Chapter 145) LOCATION: SECTION: TOWN /MUNICIPALITY: LOT NO.:BLK.NO.: SUBDIVISION NAME: �/S-1 '/a /T N/R E (o Sa COUNTY: NE BUYER'S NAME: MAILING ADDRESS: DATES OBSERVATIONS MADE USE PROFILED S RIPTIONS: ER OLATION TESTS: NO.BEDRMS.: COMMER, I, :::SCRIPTION: Residence ❑New 5a@eplace */,A / lS RATING:S=Site suitable for system U=Site unsuitable for system r ONVENTIONAL: MOUND: IN-G ROUND-PRESSURE: SYSTEM-IN FILL HOLDING TANK:RECOMMENDED SYSTEM:(optional) ©SDU ®S ❑U 2�S ❑U 10S ❑SCII If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b),indicate: /I/ I Floodplain indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- aah .R d B- B- B- B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INtTFrES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 --PERIOD3 PER INCH P- P- D 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 ELEVATION S 6 ' , _.._ E E Y � i 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 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: C . t.✓� Csa�. , - _1 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional): CST SIGNATURE: i DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) —OVER — DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY&BUILDINGS DIVISION INDUSTRY, P.O. BOX 7969 LABOR AND PERCOLATION TESTS (115) MADISON,WI 53707 HUMAN-RELATIONS (ILHR 83.09(1)&Chapter 145) 1 ON: OW /MUNICIPALITY: OT NO.:BLK.NO.: SUBDIVISION NAME: �/ sLJ �/ /T N/R E to a Q r SST 4 MAILIN ADDR SS. COUNTY: NE BUYER'S NAME: 1D � ,Q a &t& Ste/-�1 a�.✓�`�,r+-•a t--',' S-�/ DATES OBSERVATIONS MADE USE R F �js A TESTS: Np.BEDRMS.: COMMER AL DESCRIPTION: I Residence ❑New 522-place � N RATING:S=Site suitable for system U=Site unsuitable for system ONVENTIONAL: 169i N-GROUND PRESSURE: SYSTEM-IN-FILL HOLDING TANK:RECOMMENDED SYSTEM:(optional) ©S ❑U oS DU D S [a S M If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.0915)(b),indicate: /✓ Floodplain,indicate Floodplain elevation: Al PROFILE DESCRIPTIONS BORING ITOTAL PTH TO GROUNDWATER-INCHES CHARACTER Cl SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED ES GHE T TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- ah � a B- I Z B- B- B- B- PERCOLATION TESTS «T rTEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES BER IMMES AFTERSWELLING INTERVAL-MIN. P RIOD 1 P R D R PER INCH �{ a a 3 'I o 7 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 ELEVATION S 6 " - -- {{ E 1j iE t F+y , f t i i 7 t a , a < { ! - IN ; i Qt CY y S k , f 3 ; a i T 1 E i J­- 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: ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional): 13 a /SJ t- S7 ? CST SIGNATURE: DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395(R. 10/83) —OVER — _ REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS, PERCOLATION TESTS (115) DIVISION CATIONS P.O. BOX 7969 (H%090)090)& Chapter 145.045) MADISON,WI 53707 N: OWNS /MUNICIPALITY: OT NO.:BLK NO,: SUBDIVISION NAME: . s Q 1/� /T7 N/R�`�E lor, It �w js:COUNTY: WNER S BU ER'S NAME: MAr INS} DDR SS: sr Cro; I'ti� h cat/c 4 E BEORMS : COMMER AL D S RI TIO DATES OBSERVATIONS'MADE Residence .,2 XNew ❑Replace PROFILE°// 8' RATING;S=Site suitable for system U-Site unsuitable for system F NV TI NAL: MOUND IN-GROUND PRESSOR EM-IN-FILL OLDING TANK:RECOMMENDED SYSTEM:os au ©s ou ❑s ®u as ®u e—-t . lIf Percolation Tests are NOT required DESIGN RATE: ' undem.H63.09(5)(b),indicate If any portion of the te4d area is in the Floodplain,indicate Floodplain elevation: ' PROFILE DESCRIPTIONS qr _ a BORING TOTAL ELEVATION P H T GROUNDWATER-INCHES CHARACTER OF S IL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH • NUMBER DEPTH IN, BSERVED E H TO BEDROCK IF OBSERVED SEE ABBRV,ON BACK.) C"1/fie=..T4:ck B- B- B y /b0. iv y q, s, �Q�Irok. Q"Tf►.C, d f7 # Qn G � isL SL ' 9 QN �L lQ4�k B- N 5g.66 wd#, , Fly As Aw&A Ca ! ( SC ' S w .k SC ' 'Y•• B- &I 8 y ,. Stu C f w m � gy -1)�J26 Alped Scj PERCOLATION TESTS TEST DEPTH , WATER IN HOLE TEST TIME DROP NUMBER INCHES AFTERS WELLING INTERVAL-MIN. IN W ER L V EL-INCHES NU p I p RI RAPER IN H P k7/ - > P-- 9 t P- � OT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances.Describe whI Ire the hori- ntel 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. land slope, YSTEM ELEVATION 1 - , fi r a M. n y 1" . i 1 S � ie to e 1 e L 7e4 T_ N cell T oee 14 l0 Nil Zymd I 3 I s ,T 4 1 he undsrsigned `herebyJ certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified In the INIscon:in° inistrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief, ` ME print TESTS WERE COMPLETED ON DRESS: 9S �l2 Ll OX CERTIFICATION NUMBER: PHONE'NUMBER(0_P_GWsl --°: CST SIGNATURE: s` RIBUTION:Original and one copy to l gsal Authority,Property Owner and Soil Tester. HR-SBO.6395(R.02/82) —OVER- c