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Parcel 020-1151-70-000 02/01/2005 04:58 PM
PAGE 1 OF 1
Alt. Parcel 29.29.19.825 020 - TOWN OF HUDSON
ST. CROIX COUNTY, WISCONSIN
Current 'X
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): * = Current Owner
* MORTON, DAVID S & TAMARA J
DAVID S & TAMARA J MORTON
721 GLENNA DR
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 721 GLENNA DR
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 1.020 Plat: 2356-PRESIDENTIAL ESTATES
SEC 29 T29N R19W PRESIDENTIAL ESTATES Block/Condo Bldg: LOT 16
LOT 16
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
29-29N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 1246/196 WD
07/23/1997 745/258
07/23/1997 728/496
2004 SUMMARY Bill Fair Market Value: Assessed with:
48911 207,300
Valuations: Last Changed: 10/26/2001
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.020 27,300 133,100 160,400 NO
Totals for 2004:
General Property 1.020 27,300 133,100 160,400
Woodland 0.000 0 0
Totals for 2003:
General Property 1.020 27,300 133,100 160,400
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 138
Specials:
User Special Code Category Amount
018-RECYCLING SPECIAL ASSESSMENT 27.00
Special Assessments Special Charges Delinquent Charges
Total 27.00 0.00 0.00
f
Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP s y SEC. T,71 . N-R_Z.~E W
ADDRESS --dam ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT ZK LOT SIZE
p-//5 ~-w-off
b
PLAN VIEW Z
Distances and dimensions to meet requirements of I1HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
~L
0 0
f
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used S',.,y.{ gr ,(f S
Elevation of vertical reference point: e- Proposed slope at site:
SEPTIC TANK: Manufacturer: Liquid Capacity: /G6 o
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation: ~Gl, ~SZ
Number of feet from nearest- Road.: Front,O Side, Rear, O fz0 feet
From nearest property. line .Front 10 Side 10 Rear, O feet
Number of feet from: well building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank) a
SEE REVERSE SIDE
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 Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: X Trench:
Width: 12 Lengfth: 5d2 . Number of Lines: 4Z Area Built:- S
Fill depth to top of pipe: mod,
Number of feet from nearest property line: Front, Q Side, O Rear,0 Ft 3d'
Number of feet from well,:
Number of feet from building:
(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, 0 Rear, O Ft.
Number of feet from well:
Number of feet from building:
Number of.feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated /Gr o? Plumber on job:
License Number: 4 15> ;71-7
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MADISON, WI 53707
CONVENTIONAL ❑ALTERNATIVE state Plan 1D. Number
III assi an erl)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER. JADDRESS OF PERMIT HOLDER. INSPECTION DATE
Robert Bornfleth 1117 Laurel Avenue, Hudson, WI 54016
BENCH MARK (Permanent reference root) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF PT. ELEV
SE SW, Section 29, T29N-R19W, Town of Hudson,Lot#16, Presidential Est.
Name of Plumber. JMPIMPRSW No County SamtarV Perron Number.
William Schumaker 6382 St. Croix 83802
SEPTIC TANK/HOLDING TANK: X77 11"j-1 Cf F. ?
MANUFA TURER LIQUID CAPA ITV TANK INLET ELEV.. TANK OUTLET ELEV WARNING LABEL LOCKING COVER
PROVIDED PROVIDED
& 4 YES ❑NO ❑YES ❑NO
BEDDIN V . HIGH WA ER NUMB R OF ROAD. PROPERTY WELL JBUILDING. VENT TO FRESH
% ALARM FEET FROM LINE ,y AIR INLET
YES ❑NO ❑YES ❑NO NEAREST Zell rU oZ
DOSING CHAMBER:
MANUFACTURER BEDDING LIQUID CAPACITY PUMP MODEL PUMP. SIPHON MANUF AC LURER WARNING LABEL LOCKING COVER
PROVIDED PROVIDED.
❑YES FIND ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY JWELL BUILDING VENT TO FHE Sit
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) ❑YES ❑NO NEAREST 01
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH IDIANIF TER IMATI HIAt AND MARKIN(,
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:
LIQUID
BED/TRENCH WIDTH LENGTH JNO'0C DISTR. PIPE~CwG COVER AL. PIT JINSIDE UTA =P1 Is
DEPT"
DIMENSIONS jl~
GRAVEL DEPTH FILL DEPTH 11DISTR ISTR PIPE PIPE DISTR IPE. MATERIAL N I- STUMBER OF PROPERTY WELL BUILDING VENT TO FRESH
HELOWPIPES ABOVErCCOVPR F F INLET ELE ~EyN D/ P FEET FROM LINE
AI INLET
v~- ~i~ !✓s!Z' NEAREST o-i
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-
❑ YES NO meets the criteria for medium sand. TIONS MEASURED.
FI
SOIL COVER TEXTURE =11<1111 (nssF Rvnn(IN wl I I s
❑NO ❑YES ❑NO
DEPTH OVER PTH OVFR TRENCH BEU DEPTH OF TOPSOIL _ SOOUF U SEEDED MULCHf U
CENT EH EO('ES
❑YES 1:1 NO DYES ENO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH NO.OF LATERAL SPACING OHAVEL DEPTH BELOW PIPE- FILL DEPTH ABOVE COVE H
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL NO DISTR UISTH PIPE UISTftIBIII ION PIPE MATI HIAI fL MAHKINt,
ELEVATION AND ELEV. ELEV. DIA ELEV. PIPES UTA
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED COHHFCT I_v COVER MA 7ERIAL VERTICAL LIFT CORRESPONDS TO APPHOVk U
PLANS
❑YES ❑NO _ ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATI ON WELLS: NUMBER OF PROPERTY WELL. BUILDING
FEET FROM LINE
❑YES FIND ❑YES ❑NO NEAREST-
Sketch
System on Retain in county file for audit.
Reverse Side.
SI 'NAT E TITLE
DILHR SBD 6710 (R. 01/82)
TDIL.F4R SANITARY PERMIT APPLICATION cou Y
In accord with ILHR 83.05, Wis. Adm. Code
STATE SANITARY PER IT #
NEWS
Atach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER
8% x 11 inches in size.
-See reverse side for instructions for completing this application.
PETITION
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑ YES ❑ NO
PROPERTY OWNER PROPERTY LOCATION
o6e rN ke ?X S '/a S~J'/a, S T,2 N, R E (or
PROPERTY OWNER'S MAILING ADDRESS / LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
Q- G lake'.' l~ rB .6,s1te.G
CITY, STATE ZIP CODE PHONE NUMBER ED CITY NEAREST ROAD, LAKE OR LANDMARK
s VILLAGE :
O
TOWN OR
II. TYPE OF BUILDING OR USE SERVED: azz--" ` 0a0
Number of Bedrooms if 1 or 2 Family 3 OR ❑ Public (Specify):
III. PURPOSE OF APPLICATION: (Check only one in ##1. Check # 2,3 or 4, if applicable)
1. a. KNew 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. W Conventional b. ❑ Alternative c. ❑ Experimental
2. a. ❑ System- b. ❑ Holding c. ❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. E1 IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. ® Seepage Bed b. ❑ Seepage Trench c. ❑ Seepage 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):
&FA
3 l~ /S 7 Feet Z Private ❑ Joint ❑ Public
VI. TANK CAPACITY Site
in allons Total of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New xisting Gallons Tanks Concrete structed glass App.
Tanks Tanks
Septic Tank or Holding Tank ❑ ❑ ❑
Lift Pump Tank/Si hon 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) PRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code): Name of Designer:
L '
VIII. SOIL TEST INFORMATION
Certified Soil Tester (CST) Name CST
CST's ADDRESS (Str , City, State, Zip Code)
Phone Number:
e r,,
COUNTY/D AR MENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature (No Stamps)
Approved ❑ Owner Given initial T Surcharge Fee
Adverse DeterminationC0 4~~
X. COMMENTS/REASONS FOR DISAPPROVAL:
i
SBD-6398 (formerly Plb-67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber
I
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT '
APPLICATION
s
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,- iysually ev&'Y,~2 to Fs;
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;
I!. 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'/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.
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 Groundwater -
included the creation of surcharges (tees) for a number of regulated practices which Wisconsin's
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried treasure
t:
is used in your building is returned to the groundwater through your soil absorption
system or the disposal site used by your holding tank pumper.
The monies collected through these surcharges are credited to the groundwater fend adminis-
tered by the Department of Natural Resources. These funds are used for monitoring ground- t~f
water, groundwater contamination investigations and establishment of standards. Groundwater,
i''s worth protecting
SBD-6398 R_03/86)
APPLICATION FOR SANITARY PERMIT
STC - 100
i
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 Rabe-l
Locat ion of Property SE 5 4I 3~~ Section, T N - R W
Township 14GLASG
Mailing Address u St, tJ sc
Subdivision Name .-e Strd~..~t~ ( &SlaLe~a
Lot Number -
n
Previous Owner of Property R-T%.A-c~e, Y. i'1rllJr4-10C C
Tutal Size of Parcel ~•0 G Acvel
Date Parcel was Created Ln a C~
Are all corners and lot lines identifiable? Yes No
is this property being developed for resale (spec house) ? Yes ~G No
r ~y
Vulu►ne 9yJ and Page Number ggg as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
1. Warranty Deed
2. Land Contract .
3. Other recordings filed with the Register of Deeds Office
In addition, a certified survey, if available, would be helpful so as to avoid delays
oI the reviewing process. If the deed description references to a Certified Survey
Map, the the Certified Survey Map shall also be required.
PROPERTY OWNER CERTIFICATION
1 (We) eeAti6 y that a.t a#a,temen.ta on .thiA 6onm ane Uue to the but o6 my ( out )
krtowXedge; .that 1 (we) am (an.e) the ownen(a) o6 the ptopeAty ducAi.bed in tkiz
016viui)a.ti,un 6o4m, by viAtue o6 a wannan.ty deed neeonded in .the 066ice o6 the
county Regiztet o6 Deeds ab Document No. 141 3%q I , and that I (we)
pn ea e.►itty own .the. pnopoa ed a.t to 6 o~..the sewage du poe a ya zem (on I (we) have
ob-tai.ne-d an ea.bement, to tun with the above deacAi,bed pnopeA.ty, bon the
cuku6.tnucti.on o6 said 6y.6 te-m, and .the tame hab been duty neeonded in the 066.iee
u6 the County Reg" ten o6 Deeds, ad Document No.
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APP CABLE)
[1~ 6
DXrE --~SIGNE~ llATL STGN1?U
,z
. cn
9
STC - 105 rr.
9
H
SEPTIC TANK MAINTENANCE AGREEMENT
0
St. Croix County z
tv
9
OWNER/BUYER R_6_6e4-t~ ~)ar~. Ve r(A c~
ROUTE/BOX NUMBER Fire Number
CITY/STATE H~-Js LJIsr- ZIP
PROPERTY LOCATION:1-re 14, 5 t~S 14, Section, T~9 N, RW,
Town of ltx 5 o [~~a -7--..4, St. Croix County,
aI
Subdivision P`e-&s GS/4r Lot number -A
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 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 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 bya 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
I/WE, the undersigned, have read the above requirements and agree vi
to maintain the private sewage disposal system in accordance with x
M
the standards set forth, herein, as set by the Wisconsin Depart- Iv
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County Zoning Offi,re within 30 days
of the three year expiration date.
SIGNE
4- A
6
DATE d 00,
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 I
13EPARTAAENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRT, ' ' c DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 7969
HUMAN AELATIONS
(H63.090) & Chapter 145.045)
LOCATION: SECTION: ~ffO__WN~SHIV UNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME:
SE Sol 1/ ZR T?3 N/R 19 E (or oQ E7 S Iv ~SPAI E'`~'~'ft 1c
COUNTY: OWNER'SBUYER'SNAME: MAILINGADDRESS: 11`--1 ~~V~EL /A~, Ulr
S~ . C~lx ~p~,~- ~pR~j FLT ~SQI~i w l Stlat 6
USE DATES OBSERVATIONS MADE
IX Residence BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILEDE CRIPTIONER OLATION TESTS:
LEIResidence - A - XNew ❑Replace 76
6 -S- 6 - 3 8 G
RATING: S= Site suitable for system U= Site unsuitable for system
rms ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
❑U ®S ❑U ~S ❑U S ❑U ❑ S ZU 1~.'x 6Q'C ~Vf~lJl70 1. R
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: N r4• Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-lit SI ES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH Iii ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 1 6' 0LS1~ 1v®v.~C > 6' 1•o'dc-r,St1 Tsi1.3lB'~N G4s~;6-3~~-T ~ hN-9 S
B- Z g•`~~ RS•Sl II > $.-1' o.Q~' 1, ~3.1~i3~, G~-cS; L.$' II
B- 3 ~.S' 4U.L/' y >
B- 6'
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER r S AFTERSWELLING INTERVAL-MIN. PERIOD 1 P RIOD 2 PERIOD PER INCH
P- 1 4.9, Nci Swc?tU N G \--"(S l u+k 83,o S x L 3
P- Z ~uo14 , "oFtf se-& y ICU < Z ~n uvuT'WS < 3
P- G 3
P 1 e) CLS.6'
P_ Ir q
P- 3 N S•4'
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. IV- r"L r, l_ - 9 p,-)' 6~ ~uQtic1 i A2~T_ S rrtze
SYSTEM ELEVATION R5~Lf'\eeleoT - 9° o • 3
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BM - ~.o~T~P- ~f6.3' ~.o•-r Scii~ Itl = S~ wa 2 q
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:
ff?MlUR L. wGGIE°Ze't 6-l3-Sl,
ADDRESS: QT \4 ~l~k Z~ 6 CERTIFICATION NUMBER: PHONE NUMBER (optional):
EL-(- wort w s o I S"~6 ~►S-42S-o/6~{
CST SIGNATU
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
INOT l TIONS FOR n" PL. TI" o 6396 a
To be r i accurate sail to o,' ;
1. st',n;
2. ly r'
a. TANK ONLY IF ALL
a, plan;
41
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