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161-1092-50-100
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CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of ILRR, 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 40 M y Pf 4 r peg I INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used t Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer: (_Jif 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,0 Rear, 0 feet Number of feet from: well (j , building: (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, Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: / Trench: Width: Length: Number of Lines: Area Built: t„ Fill depth to top of pipe: Number of feet from nearest property line: Front, ° Side, O Rear,O Vt. 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, 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: License Number: 3/84:mj b DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR LABOR & HUMAN';ELATIONS P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS SAFETY & BUILDINGS MADISON, WI 53707 DIVISION BUREAU OF PLUMBING MCONVENTIONAL DALTERNATIVE O Holdin Tank State Plan ' Number. 9 ❑ In-Ground Pressure ❑ Mound If a-9nml NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLD ERBENC 1, ank Wash 700 2nd St eet, HuddoVl, W1 54016 NSPECTIONDATE y} H MARK (Permanent reference point) DESCHIBE IF DIFFERENT FROM PLAN. I / f j t ChUix Station REF pT. ELEV CST REF PT ELEV NE SW, Sec. 12, T29N-R20W, V.(U. o6 N•Hudl5on,Lot#5, J Wli(. Name of Plumber, .J (J MPiMPRSW Nn Coumy Rich.eeted Ho pFuv~ 1059 W Sanitary Permit Number S Croix 58936 SEPTIC TANK/HOLDING TANK: MANUFACTURER LIQUID CAPACITY. TANK INLET ELEV.: TANK OUTLET ELEV WARNING LABE❑L PROVIDED. PLOCKING ROVIDED OVER BEDDING: VENT DIA.: ``r r ❑ YES N~ VENT MATL HIGH WATER DYES ❑ NUMBER OF ROAD. PROPERTY WELL.. F DYES ONO / FEET FROM LINE euILDING ~vENrroRESH DOSING CHAMBER: DYES ONO NEAREST Z J "I I AIR INLET ~ I MANUFACTURER BEDDING: .z LIQUID CAPACITY PUMP MODEL PUMP] SIPHON MANUF ACTUREH WARNING LABEL LOCKING COVER YES ONO PROVIDED PROVIDED. GALLONS PER CYCLE: PUMPANDCONTnoLSOPERAnoNgL DYES ONO DYES (DIFFERENCE BETWEEN NUMBER OF PRQPEHrv WELL ONO PUMP ON AND OFF) LINE BuILOwG I VENT TO FRESH 1:1 YES ONO FEET FROM AIR INLET SOIL ABSORPTION SYSTEM. Check the soil moisture at th depth of pl owing NEAREST DIAMETER excavation, (If soil can be rolled into a wire, e construction shall cease until FORCE MATERIAL AND the the soil is dry enough to continue.) CONVENTIONAL SYSTEM: MAIN wIDrH LENGTH BED/TRENCH - No. OF DISTR PIPE SPACING covER DIMENSIONS l TRENCHES MArAL: INSIDE CIA uPlrs LIQUID GRAVEL DEPTH PIT DEPTH. BELOW PIPES FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MA TERIAL. ABOVE COVER E V INLET ELEV END No. D R NUMBER OF Q~2- PIPE FEET FROM LI OPER7V WELL. BUILDING: VENT TO FRESH c~ V NE: AIR INLET- - MOUND SYSTEM: NEAREST--~ ';7 r Mound site plowed perpendicular to slope uPslope: and furrows thrown Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- DYES DNO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TExruRE PERMANENT MARKER S. OBSERVATION WELLS D EPTH OVER TRENCH; BED C ENTER DEPTH OVER TRENCH; BED I DEPTH OF TOPSOIL DY S ONO EYES EDGES SOD IED ONO SEEDED MULCHED l PRESSURIZED DISTRIBUTION SYSTEM: OYES ,''NO DYES ONO DYES ONO BED/TRENCH WIDTH LENGTH. NO.OF LATERAL SPACING. G AVEL DEPTpF BE LOW PIPE DIMENSIONS TRENCHES: FILL DEPTH ABOVE COVER. MANIFOLD PUMP MANIFOLD ELE V.. ELEV. DIA DISTR. PIPE MANIFOLD MATERIAL N ELEVATION AND ELEV PIPES . O. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING DISTRIBUTION DIA INFORMATION HOLE SIZE HOLE SPACING. DRILLED CORRECTLY COVER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED PLANS. COMMENTS: PERMANENT MARKERS: DYES DNO DYES ONO OBSERVATION WELLS: I NUMBER OF PROPERTY WELL BUILDING. L OYES ONO OYES ❑N' . FEET FROM LINE ll NEAREST ( f 1-,j 1 A r / t. Z. Sketch System on l , 1 Reverse Side. Retain in county file for audit. SIGNATURE. - TITLE: DILHR SBD 6710 (R. 01/82) ` .Wisconsin APPLICATION FOR SANITARY PERMIT '~)DILHR -,j ; ~ oEggqTmEnTOV (PLB 67) COUNTY EPR TgM OR6HUmgngELqTIOf"ls UNIFORM SANITARY PERMIT # -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/zx 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS PROPERTY LOCATION CITY: 1/4 1/4, S T N, R EVV LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEARESR D, LAKE LAN ESTR OA D, LAKE OR LANDMARK SN LDNUMBER TYPE OF BUILDING OR USE SERVED ✓ 1 or 2 Family Number of Bedrooms. ` 1 ❑ Public (Specify): THIS PERMIT IS FOR A: New System ❑ Tank Replacement Replacement Soil Absorption System ❑ Repair ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. Seepaye Bed ❑ Seepage Trench System-In-Fill ❑ Seepage Pit ❑ Holding Tank. L1 In-Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. issued Total #of Prefab. Site Gallons Tanks Concrete Constructed Steel Fiberglass Plastic 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 Gallons Tanks Concrete Constructed Steel Fiberglass Plastic Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square R Feet): WATER SUPPLY: J q 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): Signature: MP/MPRSW No.: Phone Number: Plumber's Address: ( ) ' Name of Designer: COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ~ ~ ~'j / ❑ Disapproved ❑ Owner Given Initial Reason for Disapproval: Approved Adverse Determination 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 every 2 to 3 years. If you have questions concerning must be properly maintained. Have a licensed pumper clean your septic tank whenever Snecessary tate of Wisconsin. your system, contact your local code administrator or the Bureau of Plumbing, DILHR, APPLICATION FOR SAN1TAR'Y 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 devel..opment'be intended for.resale by owner/contractgV,("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 Propertjjy ,l~ ~ ~ Section I j , T N - R 16' W Township Mailing Address Subdivision Name Lot Number T Previous Owner of Property t Total Size of Parcel AC C' ; S - Date Parcel was Created d '7 Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes X No Volume C and Page Number as recorded with the Register of Deeds 42 a 3~l' 'y 5,1 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 1 (We) ceAti.6 y ,tfia.t a U, z tatementz on tii iv, 6o)cm atce =true to the bm t o6 my (ouh. ) hnowtedge; -ika.t 1 (we) am (aae,) the owylc,,L (~s) o6 the paopW.y de.6niubed in ,tki,6 in6oluliati,on;6oam, by viAtue o6 a wavcanty deed aecoaded in the 066ice o6 the County Regiitea o6 Deeds ass Document No. c i and that 1 (we) pneeen,tey oun the paopobed site boa Xhc~ suuage cii.apo4 hy,,tem (oa 1 (we) have obtained an easement, to aun with the above d"Uu.bed ptLope)Lty, boa the con,Ltnucttox o6 ba.id 6y6tem, and the same It" been duXy Aecoaded in the 066ice o6 the County Reg~,6-tUc 06 Deeds, as Docwnent No. 3 if `1 ) SIGNATURE OF OWNER - SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED Cn S T C - 105 Y r r Y SEP`1'IC TANK MAINTENANCE ACREEMEN'T y r-~ St. Croix County o O W N E R/ B U Y E I:// m ROUTE/BOX NUMBER{ Fire Number- a. CITY/STATE ziI, C, PRUI'EkTY LUCATIOIN: ? 1~Gv Section-/ 3 I' IZZ U W, St. Croix County, Subdivision Lot number Improper use "nd maintenance of your supr icy system could result in its prl.maturc failure to handle wastes. Pruper iliaintullance con- sists of pumpin- out the septic tank eVury three years or sooner, if needed, by aYlicerised septic tank L)uuiL)er. WhaL you puL into the SySCeIIi : the function of Lhu I'LIC Lank as a treat- "e=!= sta,!e -a=iLe diSR;oSal system. _`.e be e1101 b.R C LU L L'C' ('r Ve a a uxIMua, a cu.w he cost of replacement of a failing; system, Whi:;; ass =z prior to-July 1, 1978. St. Croix County - = - in AugusL of 1980, with the rucluiremellt _.:,ar agree to keep their systems prup(-r y liu air: L r S U S L Iii i to _-ee C lR) C C 5L. CCU ix CULl11 ui i:: a = signed by the a ner and by a master l i r!::t,er, ;ournc Mal, rCstricLed plumber Or a licensed pumper veri- fying LRIat _ -:-site wastewater disposal Systeul is in prupcr operating; co..`i_izz and (2) after inspection and puml)ing (if nec- essary), the se_ tank is less than 1/3 full of sludge and scum. Certification rurm will be sent approximately 30 days prior to three year expiration. 0 I/WE, the undersigned, have read the above requirements and agree Cn to maintain the private sewage disposal system in accordance with the. standards set forth, herein, as set by the Wisconsin Depart- ment of Natural Resources. Certification form must be collipleted and returned to the St. Croix County "Zoning Office within 30 days of the three year expiration date. SIGNED 'Cl-arty DATE r St. Ciloix C.)unty Zoning Office P.O. f-ox 98 Hammond, WI 54015 715-756-2239 or 715-425-8363 Sign, date and return to above address. v v r m m w N ao s cn v v,w C CD `<o= N y o a3 SsDf)i' z s~ _ 2 3 c(o(o = T; 10 p O S (D 'O a (D (D O i CD c CD (n (D $ so a 0 C, p~ 0 CD ca 0 CD OD CD :E CD CD ;`7' CD W w CD CD Cn 7 CD ~0o=mcco C ~r o 3 a o w o(D cowo(° ' cn O _ 2) C: w 0 0 C- C N 3-"c oc3oan (o = wZs c- l< Q = f ~ (n [~D w v, W O O a (CD O :3 CD CO 'a > CD w Q -4- A CD Q o < (n CD ~ my~ oDc .mom o n -4 = w n o O 0 6- c~ '2 - a w 0 o o CD aCD ~ n~i IX 0N(o =s-0 w N C N :3 (o CD m c~~m Z m a U 3 (D (D D. a i o `n 0 3 a CD =r o M (n =r C CD CD 0 :3 :3 gi) =r g (n~c,aviwCDF C m m 3cr. va=~ CD ::r o _ CD CD -1 U,' 0 co (D 0, N, =3 CD :3 =t U 0) 0 CD CD G w°~ crDC(o~(on(n w = R1 ao a uc) c c c :E :3 CD = a w o CD CO M or =r G7 (n c (o ?r' m 3 to A M. COO 0 G) Cc :3 < - CD ° a -%W3 CL C m -i (D c CD O c ~c -joo -3 to ra wa= _am =o N o < CD (o CD o p V 1 wiN/tk / s i cov pr~`i drv,S SrJrvv ,U o US T US~i' IND REPORT ON S BORINGS AND RY' SAFETY & BUILDINGS LABOR AND DIVISION HUMAN RELATIONS PERCO:T N ESTS (115) P.O. BOX 7969 (H63:'09(1)irtap" 145.045) MADISON, WI 53707 L99~CATION: SECTION: - N~ 11/ 1 /.2- /r 27 N/R 2O[ to OAL,.,,,,, LOT NO.: BILK. NO.: SUBDIVISION?NAME: COUNTY: O'b~M1tE'F~''S/BUYER'S NAME: C DUX `5-7--f%%otiJ MAILING & RESS: -70O .2 ST . l Ea/ T mil" USE /w_ 1Ju-S-O t~ ew%S- .S'vo/ NO. BE RMS.: COMMERCIAL DESCRIPTIO ; DATES OBSERVATIONS MADE Residence xNew Repla PROFILE DESCRIPTIONS: PE COLATION TESTS: N• ❑ce RATING: S= Site suitable for system U= Site unsuitable for system Sc S / / / f H f%~~ CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM:(o S ❑U ❑U ~S ❑U EIS []S HU ~ovr/fvr~ovnr pti~o-nal) /e _,t- Y7 If Percolation Tests are NOT required DESIGN RATE:/iU/~% FGp under s.H63.09(5)(b), indicate: C'G/gf s S ,L If any portion of the tested area is in the Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS 14 D_-c MqL ~T BORING TOTAL DEPTH TO GROUNDWATER NUMBER DEPTH ELEVATION CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- / S57 /o/.oy r > D ' . 17 Ate. 6 o8 Qa -6y. .-e ~a. S 3.0 ' -e-,gle es BP %b- - y j /03.1 y-- > S- ' • 5'i ' ~,u - G~ s ,1 s Gee . s' 33 7/ ,Q0' -2 9 R • S "rPxQ ~ s ~ . B-3 ~ /0/ lv ~ ~ z s ' as s~ , S 3 8,j IV. Aj B- 71 100.3 Ae'-- > 7 c/ 3 ~ ~ 1S ' L7'• ~ • S ' a . ~ ~riP 1 /S ~S p T.It,v C S B > • 33 ' 6~e~C3a . /s~ . G 7 " OB ) . s 2 . p ' a . ,Ci o , s B- 434 . CS a..rQ_ Gil . PERCOLATION TESTS --1v Ss "f 7.-4;7 Ac-,era fe7-e~,C %v,Nes TEST DEPTH WATER IN HOLE TEST TIME NUMBER AFTER SWELLING INTERVAL-MIN. DROP IN WATER LEVEL-INCHES P / r M_` PERIOD 1 PERIOD 2 RATE MINUTES _ .0 J Z / PEO RIOD 3 PER INCH r P P- P P- _ 1 PLOT PLAN: Show locations of s 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 of land slope. percent SYSTEM ELEVATION 4'f'E~- Al ' ~y' 13 @ 9T FT 3 30 r f ; 5 i4,fv ov 7`akES%T~ w~r6N F E P3 ~i © ~N, f ror,- ';Z Pips- foc>.vD 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. 1P ' DILHR-S,- RT. 3 O'NEIL RD., HUDSON; WIS. 54016 TESTS WERE COMPLETED ON: MASTER PLUMBER LIC. NO. 3307M.P.R.1 CE IFICATION N BER: PHONE NUM ER (optional): "91TALLER & DESIGNER LIC. NO. 00663 S~' -QL y Z- - CST SIGNATURE ~perty Owner and Soil Tester. - OVER - a CCU 't l' - ~ _ lpl lust t "J r:t ~~i`. t=1 3 :,t7? br of US.' 't=S f CI" €"(E iei C:P Yi ~'!F i i 1! Y _ ; zz < r L , t A SI 1.. J i § kif A_ 4l 3 :§3~t 3 _ ONLY 5. ~ p,, F 's tie AP" $ i T t'~ ~ ~ ~ oC:1 z c ;t1ti~ 171f. t it I, 10 `sc,"Ir a4 Ef - / "C' I_vice, , ,us l SE1 1 . `...sab_ P. t2n t a. v e t t°?"'v E iE Elvr t fl $ $ ,o}t °-a tle al;it.~1 § "i)3"ES$Ct'})., a,}>(a a i} and i8~. } - ) xrgl39 ~ r § v Saa t$0," t ve F,~ Cz {3t {cT}. box,, ciS to dat(`S, i"'lcit~,~ _ r` i..-i. t~..wrt.ar i9 t. a#, F%c a" La 4 yy 3 t^ 3 dE€.} 41 Bed; iPt'zi3 Lin 1w, w sand "PI 3 i ..i ~3 f. t`.c t 3?l [.i$ A,, I `S}t$`. L_tv 4.51 ay s>x ! E $r Red v, v i5 CV i _..i Sy i~{`' t t:'( .r i 't ("t ttJ 1 3~~C1 1y et'j ,}a,re. Re aC,i t4..i X34 },41C a~$ F c t ~~cC=~ g;~¢3 y equesl "i 1'3 C 1 k ~ ' t _ o than SiJ tOcal authority ill 4or i- 2?' i K,~a~T~~-y LRNr f " C~.. ~P R O J E C T E~ L U ill R E E FeA Nk 6 t C AT I n d - --o I ~ T 5 Afim L I ES E~ S~ - - M / b S Tzct - 7 ZZ eo~r'c6orn o~ t~(2K Z :a 'e ~3 i8 C X t 417 ff , 101 0 U1 1~ bn F 4Ro Ei~ I 11 FRESH RIP -.11 OBSrV),pY_(_^1 r~vI P~__` SECTION Approved Vent C~:tp Minimum 12" Above ,4 L " Cast Iron Above Pipe To Final Grade- - Vent pipe f E Marsh Hay Or Synthetic Cover_ingi Min. 2" Aggrec tIe Over Pipe 1i I Y- Distribution Tee y p e ` AI Q Aggregate Perforated Pipe Below - Beneath Pipe I Co -ling I'erminzt_:ing At I3ot t_om of System