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Home My WebLink About030-1027-10-000 r 0 CD C d : r 0) O G f9 _1 I ID , 3 n 0 aai o o CD ;r~ c, 0 • cV~o rn ww `C CD = 3 CD !D v N L co Z n M N Q= CD Q N N N N 1 N Q 3 co Cy - ~4 'S 0 CD CT ' n O C7 O O 3 CD 7 fA w 7 O Q o m c v o CD (o 0 7 co M~ U] x 3 O U1 rn 'o 3 c W V o w r* CD =;z a ti (a b O N tC CD m co d n r N OD 00 4 CD r! rr t` 0 Fl- CL M -0 -0 11 a) OOO~ N tip n ~3 NNN m y v N O m ~ A N ~ fD .r N O r.. ro rn ' p q m a 90 O eD Q N " y c El cn 1 Q I ' 0 1 ° O rt z o l ? =r 5 ° m m c t~l dX, O N C m v co a a 3 (D 5 O 7o z (D cn -i Cl) d 1.0 C/)IJ O A Z CD (D v rt C) CL C) rlr r \ o. cn --I (D co rrt c(D O~ C t L z m y m 1 CD A w 0 i ° C) Q 3 CD a) n 0 0 N -CD'z* I Nc~-v c a CD o a m 3 x. 5 .N-. CD N Q C:, U O O a a N ~(D a = N b I V N o °o I cn ' ~n CL 0 a CD DAro A CD CD ° CL Parcel 030-1027-10-000 02106/2007 02:45 PM PAGE 1 OF 1 Alt. Parcel 06.29.19.106C 030 - TOWN OF SAINT JOSEPH Current X_' ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner JASON & RACHELLE ARMSTRONG O - ARMSTRONG, JASON & RACHELLE 357 TROUT BROOK TRL HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description * 357 TROUT BROOK TRL SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 2.000 Plat: N/A-NOT AVAILABLE SEC 6 T29N R1 9W SE SE COM 385 FT E OF NW Block/Condo Bldg: COR SE SE, TH E 249 FT, S 350 FT, W 249 FT TH N 350 FT TO POB Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 06-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 01/20/2003 706419 2115/364 WD 04/09/1998 576790 1313/260 CO 1122/368 QC 742/598 2007 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 04/26/2006 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.000 72,000 132,700 204,700 NO Totals for 2007: General Property 2.000 72,000 132,700 204,700 Woodland 0.000 0 0 Totals for 2006: General Property 2.000 72,000 132,700 204,700 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 211 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel 030-1027-10-000 04/08/2005 03:54 PM PAGE 1 OF 1 Alt. Parcel 06.29.19.106C 030 - TOWN OF SAINT JOSEPH Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): * = Current Owner * ARMSTRONG, JASON & RACHELLE JASON & RACHELLE ARMSTRONG 357 TROUT BROOK TRL HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 357 TROUT BROOK TRL SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 2.000 Plat: N/A-NOT AVAILABLE SEC 6 T29N R19W SE SE COM 385 FT E OF NW Block/Condo Bldg: COR SE SE, TH E 249 FT, S 350 FT, W 249 FT TH N 350 FT TO POB Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 06-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 01/20/2003 706419 2115/364 WD 04/09/1998 576790 1313/260 CO 1122/368 QC 742/598 2004 SUMMARY Bill Fair Market Value: Assessed with: 4947 204,200 Valuations: Last Changed: 07/07/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.000 72,000 128,900 200,900 NO Totals for 2004: General Property 2.000 72,000 128,900 200,900 Woodland 0.000 0 0 Totals for 2003: General Property 2.000 42,200 96,700 138,900 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 211 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Form-STC- 104 AS BUILT SANITARY SYSTEM REPORT SEC. T _7 2N-R,W OWNER 174-' TOWNSHIP 4E 1,V ?4" tz- 7, ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•I,HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ~C,4 i- L:. L L t lad i iuc' "~Ej, iy Lem ~ ~ i Yet o reL INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: Proposed slope at site: -SE TIC TANK: Manufacturer: Liquid Capacity: Number o rlags, used: Tank manhole cover elevgtiaa. Tank Inlet Elevation: `°-a -9nt`Iet Elevation: Number of feet froc&-ae-arest Road: Front,Q $it Rear, O feet --•.._..w.._. ---from nearest property line Front, Side, Rear, feet Number of feet from: well l _i building: >L/ (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER d ufacturer: Liquid Capacity: Pump Mode Pump/Siphon Manufacturer: mp Size Elevation of inlet: Bottom of tank elevat Pump off switch elevation: Gallo per cycle: Alarm Manufacturer: arm Switch Type: Number of feet-from nearest roperty line: Fro Side, O Rear, 0 Ft. er of feet from well: Number of feet from building: Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: Length: 7 j' Number of Lines: Area Built: -250 Fill depth to top of pipe: ,1(- ,r Number of feet from nearest property line: Front, O Side, O Rear,® Ft ..5 ; Number of feet from well: Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Li id depth: Bottom of seepage pit elevation: Area Bu t: Has either a drop x O or distribution box O been used on any of the ove soil absorbtion sytems? (Ch k one). HOLDING TANK Manufacturer: Capacit Number of rings used: Ele ion bottom of tank: Elevation of inlet: Number of feet from nearest perty line: 2Fr t, O Side, O Rear, O Ft. Numbe of feet from well: Nu r of feet from building: er of feet from nearest road: Ala Manufacturer: Inspector: Dated :j .7 Plumber on job: fj ,'C License Number: 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 MACUSON, W1 53707 XDtONVENTIONAL ❑ALTERNATIVE State Plan I.D. Number: (If assigned) D Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE. Clarence Kil e Rt. 2, Hudson, Wl 54016. -?7 BENCH MARK (Permanent refer nce point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.. CST REF. PT. ELEV.. SE SE, Section 6, T29N-R19W, Town of St. Joseph Name of Plumber: IMPIMPRSW No.. County. Sanitary Permit Number: Donavin Schmitt 79172 St. Croix 79172 SEPTIC TANK/HOLDING TANK: MANUFACTURER. ,t~~LIOUID CAPACITY . TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: DYES DNO DYES LINO BEDDING: VENT DIA.. VET 7 IHIG ATEH NUMBER OF ROAD: PROPERTY JWELL: BUILDING: IVENT TO FRESH AL M FEET FROM LINE- AIR INLET: DYES LINO YES LINO NEAREST DOSING CHAMBER: MANUFACTURER 71N LIOUIO CnPn(:ITV JPUMP 11(1011 JPUMPSIPHON MANl1F AC11111111 WARNING LABEL LOCKING COVEPROVIDEDPROVIDED: LINO DYES NO DYES LINO 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 LINO NEAREST-~ SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing - 1TER MATERIAL AND MAHKWG or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH LENGTH JNO01 UISTR PIPE SPACINtI COVER JINSIDE Dln zPITS LIQUID BED/TRENCH THENCHES MnT HIAL PIT DEPTH DIMENSIONS uHAVE, DEPTH FILL DEPTH UISI H. PIPF UISTR PIP DISTR PIPE MATERIAL IN UI, H NUMBER OF PROPERTY WELL. BUILDING: VENT TO FRESH BELOW P PE ABOVE COVER ~rr I T EL N PIPE' LINE ~r AI N T FEET FROM 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 SOIL COVER TEXTURE PERMANENTMAEKEHS OBSERVATION WELLS DYES LINO DYES LINO DEPTH OVER TRENCH BED IDEPTHOV111 TRENCH 11111 DEPTH OF TOPSOIL sODUFD SEEUFO MULCHED CENTER EDGES DYES. LINO DYES LINO DYES LINO 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 JMANIFOLD MATERIAL NO OISTH DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEVATION AND ELEV.. ELEV. DIA. ELEV. PIPES DIA.. DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECT LY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLAINS DYES LINO DYES LINO UMBER OF PROPERTY WELL: BUILDING: COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. INEAREST EET FROM LINE: YE~j LINO DYES LINO - 111. 1stem on etain in county file for audit. J S/G E. TITLE 10 (R. 01/82) EInD consln A PPLICATION FOR SANITARY PERMIT D 1 L H R (PLB 67) COUNTY RRTTr1Er1T OF UNIFORM SANITARY PERMIT USATR V, LRBOR 6 HUMRn RELRTIOnS 79/'7 zr -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'hx 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS al ` PROPERTY LOCATION CITY: -t VILLAGE: L 1/4L 1/4,S ,T ~\N, R/ E (O W o NOF• ~/JSC LOT NUMBER BLOCK NUMBER SUBDIVISION NAM EST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED X 1 or 2 Family Number of Bedrooms: 3 ❑ Public (Specify): THIS PERMIT IS FOR A: ❑ New System ❑ Tank Replacement ❑ Repair I Replacement Soil Absorption System ❑ Revision ❑ Privy 7 Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. ❑ Seepage Bed Seepage Trench ❑ Seepage Pit ❑ Holding Tank System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks C ncr a Constructed Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signatur P MP W Phone Number: Plumber's Address: Name of Designer: '010 lye 7- COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved ~oo2S o o _ y S6 El Owner Given Initial Approved Adverse Determination ,ason for D' p , ova ,ourse(s) of Action Available: 1.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in a city, village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.); 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation. Failure to comply will void the sanitary permit. 9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable. 10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system, depth of the system, type of system. 11. All revisions to this permit must be approved by the permit issuing authority. 12. A complete plan including a plot plan, drawn to scale or with complete dimensions. 13. Horizontal and vertical elevation reference points that are permanent and clearly shown. 14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s) to system, building sewer and vent observation pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concernin your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin. 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 Location of Property Section T N - R W Township S i', fir'; i=L►/ Mailing Address 1-1 So k Subdivision Name Lot Number A , Previous Owner of Property d4f4Q ft- Total Size of Parcel 0 X, Date Parcel was Created Are all corners and lot lines identifiable? ~X_ Yes No Is this property being developed for resale (spec house) ? Yes_ No Volume- and Page Number L~ 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 of 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 I (We) ee4tti6y that att a.tatement6 on thin 6on.m she .tAue to the but o6 my (oun) knowte.dge; that I (we) am (are) the owner (a) o6 the pnopeh ty des eh i..bed in .th.i a .in6oAmatti,on 6oAm, by viA tue o6 a wawtan ty deed neeonded in the 06 6ice o6 the County RegiA teA o j Deeds a6 Document No. 5_ ; and that I (we) p4e6 entey own the pnopoa ed 6 i to 6on the a ewage poa a ya.tem (on I (we) have obtained an easement, to h.un with the above duc ibed pnopenty, 6on the conathuction o6 said ayatem, and the name ha6 been duty teco4ded in the 066ice o6 the County Reg.i d.teA o6 Deed6, a6 Document No. A Z", '00, IGNATURE O OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED z CA H • 'Ss STC - 105 r r 9 SEPTIC TANK MAINTENANCE AGREEMENT H St. Croix County z 43 a ye/a o 5" L4_'~F)t 9 OWNER/BUYER [ ) L jV~C M ROUTE/BOX NUMBER Fire Number CITY/STATE /L(-e, /)5-o r ZIP PROPERTY LOCATION: 14, S L- , Section. T N, R__Zj W, Town of 5 %1 St. Croix County, Subdivision 11A Lot number/V,4- 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. i 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. Ho E I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with 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. SIGNED _45 .9K& F DATE St. Croix County Zoning Office P. 0. Box 98• Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. v w 'r m x a m co e a520"30 W p p p p 1 ;K, 0 0 :3 ~Q s=w,Z a3 ~ H Q p c p w w w a °op~ pwp0 $ (D~po mXC'a) ~ w -D 0 , p cn cn ' CD 5 m Er (D - n O CD (D OD O p a C o w 09- n o w w= ~~0w0 p O c_ c p Fa 3'Z~ c*c v * CL 00 lu U). m o o ~o pad p p w w -oCOO -.vv 0> 3' p w:I- (Opc ~ N Q Q m N p D C N cn O p _ .w-. p a p o c v a- = o p Cc D) o - CL,cr 0) 06 = m 0 N CD to m Wa w N. Z D t0 N -jw N ~co O Z CD CD ID o ap(n COD M= p 3 D C cc w" Q0 CO -.0 > > a w CD FA. acog N W a c p z p C m p N CD v 3 r. v m (n CD Ch ..ate :*vw~ _ 0 o w o =c. co Nor m~9::1NU 3 3 a c Q'O c a0 cn c c aw o m w 7 w p CD cn =1 a p CD CL 2a 5 Q p l<:r CD N ~'~coCDw3 n A C t0 w p ID C a C m n a O 0(a CL p n S W 0 p: 3 0 p O° 03 N. 0 m N a o m v 3 $ o DEPA(iTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, 1 G DIVISION P.O. BOX 76 LABOR AND PERCOLATION TESTS (115) MADISO N WI 53707 HUMAN RELATIONS (H63.09(1) & Chapter 145.045) LOCATI '/4<, _/4 SECTION:/R(or) WITOWNSHIP/ s LOT BLK O.: SUBDI N NAME: ,e 111/, COU) NER'S U ER'S NAME: LING A RESS: USE DATES OBSERVATIONS MADE I NO.BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS: PER O ATI N TESTS: &Residence 2 64 ❑New iieplace It 7,~ V v . RATING: S= Site suitable for system U= Site unsuitable for system CO ENTIO❑NAL: MOUND: IN-GROUND-a URE: SYSTEM-INTANK: MM ENDED SYSTEM: (optional) L~/ DESIGN RATE: If Percolation Tests are NOT OT required If any portion of the tested area is in the under s.H63.09(5) (b), indicate: O /t'r ,5 _Zr Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPrrH-N. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) ;27 > 11, 2-- 1'~Agn .54 .3 eo -75 7 B- Z " X7 76 f ~ 7,61,1 1 B- 3 .7 Yl I, l •s,,c,, s , yam.. B- B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD I PERIOD 2 PERIOD 3 PER INCH P- P- P- / 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. 0 SYSTEM ELE"TION € 1 z i 14 ! e t E ? I i € I _I t N z a _ E r z z ~ Q ~ 3 r E _4 1,4 i 3 ~ i i i r+ r [ I 3 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: ADD ESS: Q CERTIFICATION NUMBER: PHONE NUMBER (optional): CST SIGN UP: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - ` , . v CTION OR C PL F- ...a. - SIT - 6395 ,^y T 5 roject; r. s- y m _ i L ITH SHE so, C [IV of .R a f 7 /M lye v 77. 30 7-IMACA4, r-3 _ y 0-3 7~ ~r GA' p ' 7 `t ST `P~~r P I O X ~anr 9'7 S 5 7e-,t-1 tFc. , D6. Aug//v G- iop ROX L oiYi~~,~ r