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L?t~ T ~WN-R/9W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION CfAr Du ' LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of IZIiR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM )MD r~~l 5e -o to' INDIC E NORTH ARROW 1)00,F" I T® Ietc , bex ~ Top Tele. fox BE CHMARK: Describe the vertical reference point used r Elevation of vertical reference point: Proposed slope at site: ~p SEPTIC TANK: Manufacturer: i~~~ Liquid Capacity: Pr' e a3'~ ~ Number of rings used: ' Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest-, Road.: Front, Side0 Rear, O 'l feet " From 'nearesv property line ' ,Front 10 Side IQ Rear, 0 feet J ~ Number of feet from: well, building: ~Q (Include this information of the above plot plan)( 2 reference dimensions to septic tank) 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, 0 Ft. Number of feet from well: Number of feet from building: 1 (Include distances on plot plan). SOIL ABSORPTION SYSTEM -vr Bed: Z ~V Trench: Width: 1 a Length: 00' Number of Lines: ~ Area Built: 9 Gt Fill depth to top of pipe: 3 Number of feet from nearest property line: Front, © Side, O Rear,0 Ft. Number of feet from well: Number of feet from building 940 / (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 off rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, OFt. d f Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job: License Number: 2g3 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 N CONVENTIONAL ❑ALTERNATIVE State Plan 1. D. Number: (If assigned) ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME O PERMIT HOLD ERI ADDRESS OF PERMIT HOLDER INSPECTION DATE: BENC MARK (Peimanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV.. Name of Plumber: MN,, ty. Sanitary Permit Number: SEPTIC TANK/HOLDING T NK: MANUFACTURER: LIQUID CAPACITY. TANK INLE E EV. TANK UTLET ELEV.. WARNING LABEL IL OCKING COVER n 9• / PROVIDED. PROVIDED: _ Y! YES ❑NO DYES ❑NO BEDDI G: VENT DIA.:`' VENT MATL HIGH WATER ..NUMBER OF ROAD. PROPEERTY WELL. J:U~ING. VENT TO FRESH q ALARM FEET FROM ,cam- LIN AIR INLET. YES ❑NO e'' p/ DYES ❑NO NEAREST= J? U ,77 DOSING CHAMBER: MANUFACTURER. BEDDING'. LIQUID CAPACITY PUMP M(7DEL JPUMP; SIPHON MANUF ACTHHEEt WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: DYES ❑NO DYES ❑NO DYES ❑ND GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF ERTY WELL BUILDING (DIFFERENCE BETWEEN M LINE IVENTTOFRESH AIR INLET: PUMP ON AND OFF) DYES ❑NO 00 PROP NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing u1A1,1E TI 11 IIIATI RIAE AND MARKING 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 NO. OF 111 yyy PIPE SPACIN(I COVER INSIDE DIA -PITS LIQUID BED/TRENCH ~ THEN S HIAL: PIT DEPTH DIMENSIONS ,HAVLL DLL ri FILL DEPTH JDISTH PIPE DISTH PIPE DISTR. PBIR NUMBER OF PROP ERTV WELL UILDING' VENTTO FRESH BELOW PIPE ABOVEiiXER El INLF I ELE E FEET FROM LINE T. ZP67 7-1 NEAREST---------y / y MOUND SYSTEM: AfAd- Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. DYES ❑NO SOIL COVER TEXTURE PFRMANENI MARKERS 085EH VA TI ON WELLS _ DYES ❑NO OYES 1:1 NO DEPTH OVER TRENCH BED DEPTH OVER TRENCH BEU OFPTH OF TOPSOIL SOOOE I) ISIED111 MULCHED CENTER EDGES DYES. ❑NO DYES ONO DYES UNO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH NR EONCH ES LATERAL SPACING 16HAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATEHIAL NDISTH DISTH. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEV.: ELEV. CIA. ELEV. PE'I' DIA ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING; DRILLED COHHECT LV COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS DYES ❑NO DYES ❑NO COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING. FEET FROM LINE: DYES ❑NO DYES ❑NO NEAREST I i Sketch System on Retain in county file for audit. Reverse Side. G RE-. TITL DILHR SBD 6710 (R. 01/82) ` i wnsconsin APPLICATION FOR SANITARY PERMIT 31 L H R COUNTY - OEPRRTmEnTOF (PLB 67) UNIFORM SANITARY PERMIT # - MUTgn RELRTIOnS ~ ~:~„r * ~ MMMEEMM -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS r r /T S :w 5 ei U ej- $R, PROPERTY LOCATION CITY: ILLAGE: ~1 /4s ~1 /4, S , ToZ; N, R Z 14 E (or) To LOT NUMBER BLOCK NUMBER SUBDIVISI N NAME AREST RO , L E OR LANDMARK STATE PLAN I.D. NUMBER e udaa r 411 4 TYPE OF BUILDING OR USE SERVED - G C/o Q 1 or 2 Family Number of Bedrooms: 3 ❑ Public (Specify): THIS PERMIT IS FOR A: 'Vd New System ❑ Tank Replacement ❑ Repair Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. Seepage Bed /9 x 99 ❑ 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 O0 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 Concrete 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): C. ia,Ss a 7<15 1 O k 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 MP/MPRSW No.: Phone Number: d ~ L Plumber's Address- NaR' 4f Designe 7 U &~4 /rdlo kl/w - COUNTY/DEPARTMENT USE ONLY Signatu of Issuing gent: Fee: Date: ❑ Disapproved ❑ Owner Given Initial lll~~~ l O Approved Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: DILHR-SBD-6398 (R. 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 concerning your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin. 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/contractpr,("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 I~Filt /i r Am-) Location of Property J Ix 3F h:, Section , T o~0 N- R. W Township Mailing Address ; Subdivision Name (-,F'r?N C 46 Lot Number L•,&-j- Previous Owner of Property Total Size of Parcel Date Parcel was Created 14~ Are all corners and lot lines identifia le?~ Yes No Is this property being developed for resale (spec house) ? Yes X No Volume Z and Page Number 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. PROPERTV OWNER CERTIFICATION I (We) eeAti.6y that att btatementb on thiA 6onm cute true to the bebt o6 my (our) k.nowP.edge; that I (we) am (ahe) the owner(6) o6 the property duc i,bed in thiA .in6o4mation 6onm, by v.intue o6 a wavcanty deed neconded in the 066.ice o6 the County RegiAten o6 Deed6 as Document No. ; and that I (we) pnebentty own the pnopoaed zite bon the bewage diApo-A-Z[-6y,6tem (an I (we) have obtained an eabement, to nun with the above deeehi.bed pnopeAty, bon the conbtnucti,on o6 bai,d bybtem, and the tame hab been duty neconded in the 066.tee 06 County Reg.c.aten o6 Deedd, ab Document No. ?qQ SIGNATU OF 0 ER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED H • CA _ H ' . a STC - 105 r ' a H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z t$ a OWNER/BUYER ROUTE/BOX NUMBER j1J Fire Number CITY/ STATE7-)1b'~ ZIP Section 3 ~ T 9f N, R W, PROPERTY LOCATION SO S f- Town of St. Croix County, Subdivision ~;'k(tltl /'111?77~1?hJ 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. H E I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- 1v 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. SIGNE ( JC'S'- ass` DATE st 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 r ekA s tfNl,t Ili lY MAWS. K'. .Nt PAC4 L.'., t, ..'Y/':' N.MEtlN 339'[ril U4t. ATTEh _i :CS Cy 1.4 51 4 4 9Myy'4a E 1. 29 to rBSOO r49bS ' 27409 t+r"bQ: ft, (g, n " ~a 299 PP f a yy ' JA' ab bP y. t.' X 6347 1tNP(KfA4. Cu-CL SA k- _ N ~ ~ ~ r 3 .ate ~cP cF. / 1^IaACNE: P W •,T+ 2 I bb ACHE; a jt e^G' '1 KRE A(3R> dd,9~ 3J SG °S/ t' ,`.r11. .t.T_ 1 ~'y . ar w;..FE' 4. j 1tr..Z~ ) SP?°5 K!. 25356 777 ~`v RUN g 6 4: ACRES ' Jay JyO ! "C. 32. ACNEl. Kt a t t.~ r~ W i6$ 7 152 ACRES > y> 3E19•S'Ip'E ?00 J6 ~ q ,ypQ Z .`~,a ` ~TQOSW.. T•f.t ' .p p' ~ ~v `,r.1P. 9E GRr.G 03 W-NES Se9°5'rO'E 30060' y' i< I 0 fie 7 + 03 XI-Lrl a IA/ I s~ 5!" .31 3^5 06' 0 _4•. I + SC •rHb°C i IT 1 w 3 ,9-+'S • x 30r, Z _ C 69yO LpND~ z e~ =Q•' J i _ SCALE m FEET. L t00 700 306 V3 WWTKEk,y WIN, wa, ad ,yy-~k to 33Q4...- r}+ yE Nr .H'•OF•WAT j adwil IC W ..t" IF LINE 33 33 SEE :•ryORTHER_T HIGHT-OF-*Al LINE .DETAI! $ T?N , iii CONNER . ~ ~ S . SE^TION 35 r kr9W 689°D',: . 1.. ay sPDW OF NEGINNING ` ar 'x ti' ;Y t{:•.•."a".. TRUNK O.GHWAY "1N" CWNTY TRUNK HIGHWAY "M" I• S V4 CORN" $Eel" 35 DETAIL OF INTERSECTION 12Bn, 918W A=Trz Kati: . OF DRY RUN ROAD AND COUNTY TRUNK HIGHWAY Et'm SCA E 1 40 F LEGEM1b NW HE . Ttrn ore n- .8nef..+f b W- t+ta ..•n .e+M(t M SR. 736 15. C*Al I SECTON CONKER MON IMENT FOLOC, ;OERNTSEN CAP 236 to, 23t 2: Ord 236 21 !11 .4 (2). w.t Srnr, y„+ H e_ a IN. W., Ad- C'Adl a P't-- M Sr 7J6 1: l5'. wn HM Sy/. z" ppE WE*HING 365 LBS ILINEAt FOOT , SET - ALE 01HEN Ulf COWERS STAKED WITH I'X 24' P" PIPE n.. :y WEFGW4 160 LBS/LINEAL FM n . /,off-~,T(1' 4~'x' IOCATI©N SIQTGM Dt ptlScwt o! Luc31 AffAit'-.L M•yrlof ~An[ PART OF THE Sty1M. ANG THE SElr4 SECTON 15, T211%. - RIlW I! - y~~.f^M, ra+~7'` 'Y.4'''~„[`".t'"r~-. ty~,_~,.IwAt'f^✓r}`aoar •,•..'..r7~'tiw'}> '•,C't' s~2'+w+' `a . J., -'fi s. »$W ~ '1♦. 'A ~e.~~qqa.v.+~.r 'y"~ry >.'+~'~~7• 5t y,~•~~~" ~G~~ ~5 q~.t J y.*`•.,-etas-a, s`• i~'i+i"'t'' j -T' r"• ~w« werrew,•C~.~.7rlPeyr~. .S - kq., .L.`~-'.i7~w+T"~~•s:!Nlr. a>~+r «R ,w.:~....~.isim~• n~.-tti bt+ ~ ~L'`L► w•tiS v ~ r~.. s 's Lot 5, Cernohous Addition Lot.6, Cernohous Addition Township of Troy, St. Croix County Ism 428.!91 r ► , 4 ti Ls* ACM • y 126 A011, 1.43 *4KS y„ too It 4 Q%* JU. r . Y I 0 r x m x m m (p "1 v cn w~ cuJ cU1 N 3 0 4 c v m O O X m n n m j= N ~ a 0=` 3 -o9 SSw r.~ o c o w ~O C S (D '6 Q CD (D (D p N _N D _ (D (n m (n 1nn~ g O 130 O_ Q m w O -M = (D C 1 m CD W a) Co CD CL 4-1. CD . « m -Si m ? (D P m 3 Q O o 0O m m co r 0 CD _ C: (0( 0 S (O O w O a w S O p = w C C C L U1 ZC O c 3 C 0 a m c l< Q = O w S O c S m • - CD _ co D "gym w m -tZ mmc c•(pQ0 (n _D c o r. o m - w m m° c S a ^ m 0 CL Q = w m :3 rn C4 CD ' co z =r 2) r' a CD mom' 0 CD Z o m m 3~m m a a m c, O . a m cD O N (o m a 1 a ; w o $ 171 Qcn m S-n c j m a mSa(m c CD0 UU)wmm~ C m va m N = o CL m ~ 7D ]7 ~a~ w==t 1 boo (n`<p?C(a_ a ~1 c CD =3 CD Cc cn (n -1 5;7 aoI ccnc°0awo" 171 = w w m OQam N CL0 (D a c `G (O m 3 n C 'n (p m o (n' m o m O ` c O. O = o (o O• c (n V O. C w m -i m C m C~ m = c a ~c Sw~..m 40 CL (D 0 wear *=3 0-11 o m w n= a o CD = ;y 3 CD =a m o U) z o o r DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS ;INDUSTRY, DIVISION OkBOR AN P.O. BOX 76 HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 53707 (H63.090) & Chapter 145.045) LOCATION: SECTION: OWNSHIP/MUPI tehl Atl 1Y: LOT NO.:BLK. NO.: SUBDIVISION NAME: SW ~W4 1/ 3S /Tza N/R ►9 E (or W C - ~ o wuv s P>'pD COUNTY: BUYER'S NAME: MAILING ADDRESS: S-~'~ ~~~X ~`~IVrv~s }4ti~. ~svn~ 3 o g N . u. S (21 v ~ L~ s 1 ~ 4~~ z Z USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: I PROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence New ❑Replace Il 1 _ SL ~l rl 7 ~ RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: JITANK: RECOMMENDED SYSTEM: (optional) ®S ❑ U ❑ S ❑ U LKS ❑ ❑ S CRU ❑ S ~L'SJ U N-L.' X 19~ d-o&3 ;-:ak3DwA k.. t D If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the A ` under s.H63.09(5)(b), indicate: (al,_~ SS LFloodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-114@1 "ES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 1 -1. b' \b\•O -2 6' 1.1')X'Bns11 ls; y Bnsl, z/.g 73hKIQ~i s B- Z 1.5~ ~ou,S' > -1. 5' 1•~' , 1,3~ ~I V, 3 S, C), , J B- S 6,8 99,`7' lUt~v > B- PERCOLATION TESTS. TEST DEPTH. WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERIOD PER INCH 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, 1 IJ~'~1 ?1%V . _ S( ,s , pPc GC 'p SYSTEM ELEVATION w1 !i 2 t 2' ~ L t b oN -T-bD of= ( I i LcC~Huw 4rti3u fox N-T I,3~_ c.)P_-1j I g b o9 C.'•_ QF,_. /j LAST 2{ ftvl Nip 0~N~11 [ C YJ, OF A'2,AjpP-t i7J t i e E ~ r 1 r s ~4~Y P. ~a4h NFp /i" o~T~ \ 2$O. Ll I S°t ^ E:. Ins 100 SEc, 35 I, the undersigned, Q;eby 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): '2i 4 1 x Zz.6 I u-SWOlt-m' w syo 7 silo ~S- V zS-oily CSTS;I= AT RE: !Y DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. D I LH R-SB D-6395 (R. 02/82) - OVER - INSTRUCTIONS R COMPLETING FORM 115 - I ID - 6395 To r. a -urate soil test, ynirr report must include: 2. T indicate whethe is is a residence or corm ect; 3, or corn u planned, 4. -.'.tITABLF, " 'Isndr; TANK OKILV IF AI.L :Mr i ..anent; t exernp TextUres I - L ti / pt m D a I J y A ' w w I oopr f'y par ~,dv~l' I~Ile a'`t' J 1 Pv ~ 2 79 , 45ed elev. ~6. p i .Nome 11 DOD f h be` Bap - - >a,rh9' rniti~ i Eleo. %oV ba 4A, _ tax 19 P~eplace~e~T_ 96, ~ ` o h+ 14 Kip bo' ~I~ RP P elE l o~~~ a S C',~rne,r Lax NF, Co~n~r