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HomeMy WebLinkAbout020-1160-10-000 t c • 7 <D = H• r} M n o C C N r^ A (D (D V, M o I p~ N p m c m iv • d N' Z` N 000 1 cD o IV CL 7 O N -I 0 ° R O O 7 V71 O cn O~ p1 (A C O O 7 O ~ l~ 7 N (n O O Q i CD CD N Q CD 9 CD N 07 n 00 0 N CD C1 (n C~1 w w c 0 r: I'D 'n z (0 (0 CL O C n 00 00 (-n O N !'T C i I'd o 3 0 (D _ d y z 0 0 0 t+~1. 0 H. ;t rt H N O (n l7 o N Z rf 93 - 1 T v S 3 U1 (A (R p) U' o F- o C)" M v 0 =r CD M in r z oo ? °1 m CD 110 tw o 00 N) v a o N N rT 7 z zoo0 p z _ F-3 0 D a ~r 7 1 CD @ CD N LTJ N r CD N' W C CD CD w (p 2 00 00 v~ r y a 3 (n 7 -4 N F-J rt -,o C M W N' t%j v a A z O 7 0 F F- 0 7 Ln co d z S (D W cn N O o ° n rt Q z o z n ~ O C F ° o N. o z m f-h (D ON x rt Q rt O a W p I m, _ ~ 3 w c z a O O 0 m I a N S I y I I o. A ti I N p a { 0 A O CD 4Q N I CD 0 0 o o a ti i Parcel 020-1160-10-000 02/14/2006 01:07 PM PAGE 1 OF 1 Alt. Parcel 16.29.19.916 020 - TOWN OF HUDSON 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 O - HOWELL, DANIEL C DANIEL C HOWELL 563 SPURLINE CIR HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 563 SPURLINE CIR SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 2.540 Plat: 2216-NORTH LINE STATION II SEC 16 T29N R19W NORTH LINE STATION II Block/Condo Bldg: LOT 25 LOT 25 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 16-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 11/22/1999 614234 1472/ WD 07/23/197 7 2005 SUMMARY Bill Fair Market Value: Assessed with: 92781 244,500 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.540 71,200 178,200 249,400 NO 05 Totals for 2005: General Property 2.540 71,200 178,200 249,400 Woodland 0.000 0 0 Totals for 2004: General Property 2.540 49,400 145,500 194,900 . Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 122 Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSMENT 27.00 I Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 0.00 Fo rm - S '1' C - 1 04 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SEC. f~ T Z~ N-k ADpRESS/~V4' ST. CROIX COUNTY, WISCONSIN /G SUBDIVISION., (/G/t6i lore LOT LOT SIZE PLAN VIEW Distagces and dimensions to meet requirements of. H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM •d d t1V - Ioo.o~by s.T 7~ . e~rn5 s" 140 Lyy~LcJ LyY yy " 8y 7- INDICATE NORTH A"iROW BENCHMARK: Describe the vertical reference point used -To,p dF C'-S_-~-- Elevation of vertical reference point: A00. d Proposed slope at SEPTIC TANK: Manufacturer: (,t>,~; ,5 Q, r Liquid Capacity: /00 a / Number of rings, used:_ Tank manhole cover elevation: -3j. (.0 Tank Inlet Elevation: 9 S ~S$ Tank Outlet Elevation: 9 S • (o $ Number of feet from nearest Road: Front,Side ,0 Rear, 7s feet From nearest property l ine FrontSide,ORear, 0 (0 5 1 CCL Number-of feet from: well ~eo building: /g~lro~ 1fousf ~j Z3 a~ow• S t' ~arKdr (Include this information of the above plot plan)( 2 reference dimensions to -;(,-htic tank) 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, Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed. Co v ~g y j o 1 Trench • - Width: Length: 3 C Number of Lines: 3 Area Built:VIyS ~ Fill depth to top of pipe: L{ L Number of feiei from nearest property line: Front, Side, O Rear,O Ft.// Number of feet from well: 43 S , , Number of feet from building: Z9 (Include distances on plot plan). - SEEPAGE PIT A~ Size: ~V 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, O Rear, O Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job: W License Number : /1. /17 l~ I 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR LABOR & HUMAN RELATIONS SAFETY & BUILDINGS P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION .MADISON, WI 53707 BUREAU OF PLUMBING CONVENTIONAL ❑ALTERNATIVE State Plan I.D. Number: ' ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound If assigned) NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPE- ION ATE: Tim Ecker 525 N. Lamon #5, Hudson, WI 01 e"5- 30 BENCH MARK (er Pmanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: R F. P . ELEV.: CST REF. PT. ELEV.: W NE Secrion 16, T29N-R19W, Town of Hudson, Lot#25,Northline Station Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Doug Strohbeen 5432 St. Croix 64898 SEPTIC TANK/HOLDING TANK: MANUFACTURER: / LIQUID CAPACITY, TANK INLET ELEV.: TANK OUTLET KEYPR CKING COVER ~ OVIDED: v✓✓lVV/ ~J p YES ONO BEDDING: VENT IA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: ING: VENT TO FRn MFEET FROM lAl L~ YES ONO l~ OYES ONO DOSING CHAMBER: NEAREST MANUFACTURER: BEDDING: LIQUID CAPACITY. PUMP MODEL. PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: YES ONO OYES ONO OYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS()PERATIONAL NUMBER OF PROPERTY WELL. BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE' AIR INLET: PUMP ON AND OFF) OYES ONO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL q ND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until =FR the soil is dry enough to continue.) CONVE NTIONAL SYSTEM: O.OF DISTR PIPE SPA ING COVER INS IDE DIA BED/TRENCH WIDTH ETRD RENC 5 IqL; #PITS: LIQUID DIMENSIONS / PIT EPTHGRAVEL DEPTH FILL DEPTH DPIPE DISTR. PIPE MATERIANBELOW PIPESABOVE OVER. END- PROPERTY WELL: BUILDING: VENT TO FRESH / PIPES FEET FROM LINE: AIR I LET ~ MOUND SYSTEM: ,0 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- OYES ONO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TEXTURE POBSERVATION WELLS. DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED: OYES ONO DYES ONO CENTER. EDGES: SEEDED. MULCHED: OYES ONO OYES ONO OYES ONO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH NO. ()F LATERAL SPACING: GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER. TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING. ELEVATION AND ELEV.: ELEV.: DIA ELEV.: PIPES DIA.: DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED PLANS: YES ONO OYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: OYES NO DYES NO NEAREST Sketch System on Re ' in county file for audit. Reverse Side. y SI U E TITLE: DILHR SBD 6710 (R. 01/82) WISC°nSln APPLICATION FOR SANITARY PERMIT D ILHR COUNTY DEPRRTR1EnT ov (P L B 67) -1nDUSTRV,LR80R&HUTRnRELRT10nS UNIFORM SANITARY PERMIT # ~ y 899 -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 # U41n 134 PROPERTY ACA ION 5 W1/4 1/4, S 6 , LOIN, R /q & (or) 4 T F: LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK ]STATE PLAN I.D. NUMBER J~` S a 'p TYPE OF BUILDING OR USE SERVED 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): THIS PERMIT IS FOR A: V 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 ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank L~ 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 Gallons Tanks Concrete Constructed Steel Fiberglass Plastic Septic Tank Capacity O X Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: 4cir is 4r- IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total *Of Prefab. Site Gallons Tanks Concrete Constructed Steel Fiberglass Plastic Septic Tank Capacity Lift Pump/Siphon Chambe{ Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): WATER SUPPLY: g Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of ~tl private sewage system shown on the attached plans. Name of Plumber (Print): Sign ure: D l r S~roc- MP/MPRSW No.: Phone Number: 2111 3233 PI b r Ad ress- 7 f/--. Name of Designer: COUNTY/D TMENT USE ONLY Signature of Issuing Agent: Fee: Date: r ❑ Disapproved _S6 6. ❑ Owner Given Initial 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 r INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 r j 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 S T C - 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 4 7ea.. Location of Property 5W Section T N - R W Township &u.(S©j2 Mailing Address g , Subdivision Name Ao✓-fk ~i x ~`7~ce7`i`O v► Lot Number Z Previous Owner of Property ~ s~~ t Lwis fir' r /A, pe7~er se r Total Size of Parcel Z- Z-> gc Date Parcel was Created Are all corners and lot lines identifiable? x Yes No Is this property being developed for resale (spec house) ? Yes ,x No 66® Volume and Page Number` as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: K11. 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) ee4ti6y that aU .6tatement6 on this 4o4m ate tAue to the best o6 my (out) knowledge; that 1 (we) am ( ane) the owneA (.s) o6 the pno peh ty de6 ct bed in this in6onmati,on jonm, by viAtue of a waA&anty deed neeonded in the 0j6ice of the County Reg.usten of Deed6 ass Document No. _393Z_5-& ; and that I (we) pneb entty own the pno poz ed .6 to Jon the s ewag e pob aka ydtem (on I (we) have obtained an eabement, to nun with the above des i.bed ptopehty, 4on the conbttuction of said b yb,tem, and the same h" been duly neeo)Lded in the 0jjice 06 the County Reg"ten of Deedd, as Document No. ;37 ~zAJ& ) . ✓ Leg& SIGNATUR OWNER SI ATURE OF CO-OWNER (IF APPLICABLE) S" .Qv S-- 85- DA E SIGNED DATE SIGNED L H ' H 9 ST C- 105 r SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z d y H OWNER/BUYER ROUTE/BOX NUMBER S-ZS IV, L e~rr•v~.• $ Fire Number CITY/STATE ue,1-5 'LIP S ~0/(o PROPERTY LOCATION: W14, NE k, Section, T22N, R /g 0 Town of , St. Croix County, Subdivision &J,tga Sfaf~y h , Lot number Z$r 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. t 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. yo I/WE, the undersigned, have read the above requirements and agree LO to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- ~u 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 DATE St. Croix County Zoning Office P.O. Box 9B• Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. 0 c v c co s:'<> o c v d E - - ~b o 3 (D m 01- (D E (D y co >>4 C C ' V C.,..: V y N w a>, v0. C _N Nr 3 ca L L vi 0 c y ~'v ~v a? W oco~c-o cacco h 3 > 0 3 010 cc -~i U) 10 E-4) C c (ti O= 0 O N t~ Q a~ w = o V N~~~ceo ° N ~ N N LIJ c co cco co cn = 10 N o to 3 y 3 c co p E I ~t c~ v r ' ° eo cn cc M m -C 0) cc w 3t~ vc.. v t N N E V N-0 3 O f t U N N N C Z C c F- =m- L.a~m N Z N LM 0 M= c3o 4? `i° it vii N I- N m` a C 0)(D vi o 0 c~v o L a~ 32 a) 0)0 Coco a- - q M c om (m 0<0 >0U)i 2 m Q cl ~ ~ _c> CWCO~O °N'o oc3ca>,~ .c co at CM Z _N C ° E p >O, :3 Y 0 0 E ~o m o C c c C6 cm a co N N p U E 0 m C CD i T+ -.mow C1 Go ~ ~ a Y ` m a w (D c 0- 3yNO3~ 00 cm ~ b T o a a o `rcooomca ~r~o e cm 131 rn N M ns O ~ OC 2 co t t L a i p c- E f rJ c O >O, i i N C N N 3 `p rN. co 0 o 0 E cv ai tw co t (D N c o~ 2 N ..I DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION P.O. BOX 76 LABOR-AND PERCOLATION TESTS (115) MADISO N WI 3707 HUMAN RELATIONS (H63.090) & Chapter 145.045) : SECTION: TOWNSHIP/MUNICIPALITY: OT NO.: BLK. NO.: SUBDIVISION NAME: LOCATION sw '/4 '/4 14, /Tz7 N/R11 E (or HUPTOA.) 2s_ if/c>P Ci~F 5-;!f710A) CO NTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: Sy- Cl oix 5 ~{7E~SO.J 6!41,0A0 1W • Nai'l'- ~uP re c) 40/S USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: ERCOLATION TESTS: Residence New ❑Replace LuT tl4v 7,4I'M 5 3 SO"- E$ ' S'CS .Se I QU~eel, ~,epv % JOgAI RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) /f'SQ •l~j-, R IS ❑u R IS ❑u a s ❑u ❑ s ou ❑ s au 1; "V,41e / - 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: Floodplain, indicate Floodplain elevation: 1AJ DXCiA10y- Fr PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE BBRV. ON BACK.) i i •33'D,F/Ja•S~ .33',B,,r. IS,, .33'L •(3a. - s, X1.0 B/ /O.o 3,3 y /0 0 9.) v Cs ' s yi ' Ae`- a . S, L ,v B- L 5 5 3 ' ~•S Awl GR . 3 CS . B-3 ~ 16.3s r ~ ~ • 2. 0,0 ' /~1 . ~ , . ~a ' IV/- . Z ,eH , 33 ' ,v. aAM, 67' I3AI CS B- 12.61 W.01 • •yZ'Ae-,&J.1,14.1, •~S'av. , U33 a• .0 -s . >/1 , (3I.1vI~ C s G~ B- 6) 2- t i .7f oAM S03' BA, 04-", 3 - N . 0;VM r B- 1.0 ' fA) PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P- L 4.~ U s P- P- 2 Z Z v a P_ _ D P- c 14& v .TF 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. 8077011 n /YCOA710~ ~ y'D • fr• SYSTEM ELE TION L° 'I Vi=e d E E ( F k ~ i 10 JOY AM` . E t i ~ I ~QI. ~0 E s.- L k € 03 D ~Ili zo - i i ~ I ~ I Lod ~-raE- ~ ~s I, the undersigned, hereby certify that the soil tests reported on this m 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 O • Y - TATE VEIL SITE EVALUATIONS (PERC TESTS) / 0 ADDRE : MI VNHSOTA LICENSE NO. 00663 CEFj,TIJCATION~MBER: PHONE NUMBER (optional): WISCONSIN LICENSE NO.55-02482 JJCC SS d L y L- 13P6 - .os7~TETT flWiiVa/N ri.* L7ii71JQON' W1 M016 CST SIGNATUR : RT_ s5ii[::.a. •r i~iili+r ~i DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. i DILHR-SBD-6395 (R. 02/82) - OVER - e 0 - L-.SING FORM 115 - SBD - 6596 `Co be a ( i to : report mrast inclUde. 1. Cor plet~ 2. ise sectic indicat his i )ject; N1 !Sol G ; if us 4. k sy tem; E plot clan; 7, eferred. 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