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Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM P Bed: Z Trench: Width: Length: A Number o F Lines: Area Built: F'x �r, Fill depth to top of pipe: Number of feet from nearest property line: Fr nt, `O Side, O Rear,O fit . Number of feet from well: 8 Number of feet from building: a (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 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: a 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 fob: License Number: ��� 3/84:mj i 'r Form - S T C - 104 • AS BUILT SANITARY SYSTEM REPORT `n R OWNER Qt D 1�, �roA,) I TOWNSHIP 12Qair1T-L'10 SEC. T N- W t ADDRESS ' �� ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of ITZHR 83 SHOW. EVERYTHING WITHIN 100 FEET OF SYSTEM 0 Lie �l tx �97j�,� lovU�4 / 160' S/ 93 ?5 ' f' 1/0 �j� (' INDICATE NORTH ARROW U BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: Pr posed slope at site: f SEPTIC TANK: Manufacturer: Liquid Capacity: Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,O Side o Rear, O feet From nearest property line : Front 10 Side,O Rear,O feet Number of feet from: well , building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O'.BOX 79,89 BUREAU OF PLUMBING MADISON,WI 53707 NW4, SW4, S9,T29N-R18W CONVENTIONAL ❑ALTERNATIVE State Plan I.D.Number: Ilf assigned) Town of Warren ❑Holding Tank ❑In-Ground Pressure ❑Mound 110th Avenue NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION ATE: Harold Brown Roberts WI 54023 3 '96- 4`coo BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: rTREF.PT ELEV. I Name of Plumber MPYMPRSW No.: County: Sanitary Permit Number: Thomas A. Wan 2 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPAC V-. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED. �i DYES ❑NO DYES ONO BEDDING: VENT DIA.: VENT MATL. HI ATER UMBER OF ROAD: PR OPERTV WELL: BUILDING.IVENT TO FRESH nLA FEET FROM LINE AIR INLET OYES ONO S ❑NO NEAREST DOSING CHAMBER: MANUFACTURER JBIDDING LIQUID CAPACITY PUMP MODEL. JPUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: EYES ENO OYE S 1:1 NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM "NE AIR INLET PUMP ON AND OFF) 1:1 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: WIDTH' LENGTH. NO.OF DISTR.PIPE SPACING. COVER INSIDE DIA &PITS LIQUID BED/TRENCH TRENCHES MATERIAL' PIT DEPTH DIMENSIONS `- GRAVEL DEPTH FILL DEPTH IDISTH PIPE DISTR.PIPE DISTR.PIPE MATERIAL. NO.DI R. NUMBER OF JPRO WELL BUILDING V NT TO FRESH BELOW PIP S ( ABOVE COVER EL V INLE ELEV.END' PIPES LIN AIR INLET / 2, FEET FROM ,5 ;v� f NEAR EST--► 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. OYES ONO SOIL COVER ITEXTURE PERMANENT MARKERS OBSERVATION WE Lt 1:1 YES ONO OYES ❑NO DEPTH OVER TRENCH/BED fDEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER EDGES ❑YES 0 N 1:1 YES F-1 NO DYES El NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH TRENCHES: LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO DISTR DISTR.PIPE DISTRIBUTION PIPE MATE HIAL&MARKING ELEV.. ELEV.. DIA. ELEV. PIPES DIA.. ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS F-1 YES 1:1 NO 1:1 YES El NO COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING. FEET FROM LINE �0 OYES 1:1 NO DYES 1:1 NO NEAREST P gc/ Sketch on System v � g'R,tain in county file for audit. I Reverse Side. __.___.__ SIGNATURE ITITLE Zoning Administrator i DILHR SBD 6710(R.01/82) 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. 1 Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed puimper'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 owners name and mailing address. Provide the legal description where the system is to be installed; Il. 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: Instal Iing,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. 4 IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8'/2 x-,.11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawr tp 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 cominoniy known as the groundwater protection law. This change in statutes was the resu't of over 2 years of steady negotiation and public debate. The groundwater bill Ground ater �. included the creation of surcnarges (lees) for a number of regulated practices which Wisco S nra ° can Jul),effect groundwater. The surcharge took effect on 1, 1984. All of the water that buried {teasa.re r; used in your building is returned t:. the groundwater through your soil absorption system or the disposal site used by your holding tank pumper. � �( The non!es c:7iiec;teci through these surcharges are cled ted to the gr.iunrwater fund adrn nis- ° b: er by °ie department of N tural F­sources. These fund's are used for r,�onitor no grit! `1- MMMr t t., C" 3:#r'.lw f' *r 1::.7nt;xrnlri 1tlC. ? it 'stioations arld :'st.. hrn?(41t cf st idFc 1c 5,r©.. cri arcaec"rig L i4s1 G3';'tiRj :(�Zt=il!L7 SANITARY PERMIT APPLICATION CO�; ���jx In accord with ILHR 83.05,Wis.Adm.Code STATE SANITARY PERMIT# 10 P 776 —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 WNER Qi.Q PROPERTY LOCATION 0 10;1 lc1'/a S'i,I%a, S T o� N, R E (or W PROP TY qqW ER'S MAILINGADgRESS LOT NUMBER BLOCK NUMBER SUBDIVI o p r'�� E PHONE NUMBER CITY RE LAKE OR LANDMARK CITY-SATE ZI � ❑ VILLAGE: r .& a tJ'P L�t%fS II. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family J OR ❑ Public(Specify): III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. El New OR 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. Rponventional 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. 9 seepage Bed b. ❑seepage Trench c. ❑See a e Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 14. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROP O D(Square Feet): ` luare U - .5v r�5'6 Feet &I Private El Joint ❑ Public VI. TANK CAPACITY Site In aIIons Total #of Prefab. Fiber- Exper. INFORMATION Manufacturer's Name Concrete Con- Steel glass Plastic App New xisting Gallons Tanks A structed Tanks Tanks 'S Septic Tank or Holding Tank Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ El VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name(Print): Plumb is ignature:(No Stamps) MP/MPRSW No.: Business Phone Number: dh'i s J� 4An 3a3 1 Plumber's Addr ss(Street,City,State,pp Code): / , ` Name of Designer: Q le fd�°Y //S' 4/r VIII. SOIL TEST INFORM ION Certified Soil ester(CST)Name � CST# CST's ADDRES (Street,City, to ,Zip ode) . Phone Number: Zoo �A ot 1�0aa IX. COUNTY/DEPARTMEN USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) YT Approved ❑ Owner Given Initial Sur ge Fee Adverse Determination �0 '()� X. TIMMENTSIREASONS FOR DISAPPROVAL: n SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber I s 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 CC/ f /v Location of Property ( fit , Section , T N-R0 W Township �l! Y101�1 Mailing Address Address of Site Subdivision Name . Lot Number Previous Amer of Property Total Size of Parcel ,(� r� Date Parcel was Created Are all corners and lot lines identifiable? Yea 2t No Is this property being developed for resale (spec house) ? Yes No Volume �j and Page Number as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A Warranty Deed which includes a Document number, volume and Dane 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) ceAtt6y that att statement6 on thi,6 �onm ahe thue to the best o6 my (ouh) hnowtedge; that 1 (we) am (oAe) the owneA(�s 06 the pnopenty deachi.bed in thiA in6oAmat on 6onm, by viAtue o6 a waAAanty deed ne onded to the 066ice o6 the Count RegAAtex o6 Vee6a�s Vocument No. ��' 7/� ; and that I (We) pteaentty own the pnopoded bite bon the sewage di.6pod .ayd em (on. I (we) have obtained an easement, to nun with the above d6chi.bed pnopeJrty, bon the con,6tAucti.on o6 eai.d ayeterm, and the same had been dut recorded to the 066tee o6 the County Reg-i6teh o6 Veedd, ae Vocument No. P SIGNATURE OEP OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED i •�, ....._. _.. ... __ _ __ _. _ -___ _ ___ _. __ __ _.__ _ .___ __ _ - _ __._____ _ __ _____- __ _.._ . � __ __ __ ______ _ _. _ .___ __ __ .. _ _ _ _. __ ___ __ _ _ __._ __,. -. ___ -- _ _- __ __ • _ . _ . _ _ _ _ __ _ __ _ __ __ _._- _.__ __. , __ _ _.__ _. __ __ _. .__ __ __ __ _ - _ _ -. _. __ ..._..._. .. .. __._. . _ _.. - - _ __. �,_. . ._ _____ -_ _ _ ` � , _:. _. .._., i __r.._-__ i Th Po 6"o 9 a "rk ©vet y'Perf Few 1ark = U� a sQIll 1)lent lot �3 �b Qa �b l F �9 d > r � ¢ =Ya 4•` a z < _ f 4 Z � . w✓ lift 4wf WO) , —N ME EL- x � 1^ . i rIT"- , oi v fi Y ri z . cn H 9 STC - 105 r 9 SEPTIC TANK MAINTENANCE AGREEMENT o St . Croix County z d a OWNER/BUYER ROUTE/BOX NUMBERr( Fire Number ---- CITY/STATE Eo iE ZIP 7o 03 PROPERTY LOCATION40 )4, ':3L 14, Section, T o? N , R W, Town of hia 0-re )I , 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 IE the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St . Croix . County residents m_ y 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. H 0 E z I/WE, the undersigned, have read the above requirements and agree M to maintain the private sewage disposal system in accordance with H 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 . i 1 � ! SIGNED DATE St . Croix County Zoning Office P .O . Box 98- Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign , date and return to above address . t INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 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 this a new or replacement system; h. 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; 0. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale=, is preferred. A separate sheet may be used if desired; 8e Make sure your benchmark and vertical elevation reference point are clearly shown,and are permanent; 9. Complete all appropriate boxes as to dates,names,addresses, flood plain data, percolation test exemp- tion, if appropriate; 10. If the information (such as flood plain,elevation) does not apply, place N.A. in the appropriate box; 11. Sian the form and place your current address and your certification number; 12. Make legible, copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL.. TESTERS Soil Separates and Textures Other Symbols st - Store (over 10") BR -- Bedrock cob - Cobble (3- 10") SS - Sandstone gr - Gravel (under 3") LS Limestone �s - Sand HGW - High Groundwater cs Coarse Sand Perr, - Percolation Rate coed s - Medium Sand W - Well fs Fine Sand Bldg - Building is - Loamy Sand > - Greater Than °sl Sandy Loam < Less Than "I - Loam Bra -- Brown %l - Silt Loam B1 - Black si - Silt Gy - Gray *cl - Clay Loan) Y Yellow sc.l - Sandy Clay Loarn R - Red sic[ - Silty Clay Loam mot - Mottles sc Sandy Clay w/ - with sic - Silty Clay fff feLv,fine,faint X Clay cc - cornmon, coarse pt Peat nim - Many, rnedium w -- Muck d - distinct p - prominent HWL - High water level, Six general soil textures surface-water for liquid waste disposal BM - Bench Mark VRP - Vertical Reference Point TO THE OWNER: This soil test report is the first step in securing a sanitary permit.The county or the Departrnernt may request ve6fication of this soil test in tlae fie(cl prior to permit issuance= A complete set of plans for the private sewage systerrr and a permit application must be submitted to the appropriate local authority in order to obtain a perrnit. The sanitary permit must he ohtained and posted prior to the start of any construction. 'rINDUDEPARTMENT Y, OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, � DIVISION LABOR AND PERCOLATION TESTS (115 P.O. BOX 7969 ) HUMAN RELATIONS \ / MADISON,WI 53707 r ' . (1-163.090)&Chapter 145.045) LOCATION: '' aa SECTION: p� UNICIPALITY: LOT NO.: NAME: W '*11.J� AM N/R ( JtjDjNhaH_31 ) ✓c s—. COUNTY:• A r1jtLELEL5;S UY�jR'S NAME: MAILING ADDRESS: Sr r° i d l L�l�'0 �d r'O Cr 7�S *. USE DATES OBSERVATIONS MADE Residence NO.BEDRMS.: COMMERCIAL DESCRIPTION: ❑New PROFILED S RIPTIONS: PER OLAT ONCT�ESTS: 3 Replace 14 I- ? 8 n RATING:S=Site suitable for system U=Site unsuitable for system / ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDINGTANK:RECOMMENDED SYSTEM:(optional) CAS ❑U ®S ❑U ®S ❑U ❑S ®U OS ®U eenv If Percolation Tests are NOT required DESIGN RATE: If any y portion of the tested area is in the under s.H63.09(5)(b),indicate: 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.) ,61s ' Zoe,614 Z f, IsZAR' -??' B- � 9, 0 Z 00BlS ' 2 6015n �'s"d�a sVG'I' B- B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD PERIOD2 PEFUOD 3 PERINCH P- t S'v No /4 °� P- 3A0 D p P- ,5�0 48 9 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. q,-* SYSTEM ELEVATION !D,�O BOe e _ E EQCO�e m w — r F ' ' �� � 1 �t 3 �{ S 1 ^ _._ • E E 1 I - t N F .- rb c y J Ir..�s err" s t, _ . — ' t S .__�.�L 1 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( / TESTS WERE OMPLETED ON: ADDRESS: / CERTIFICAT MBE PHONE NUMBER(optional): CST S URE: DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —OVER—