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Parcel 030-1044-50-000 03/30/2005 10:45 AM
PAGE 1 OF 1
Alt. Parcel 20.30.19.161 B2 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
"
GRANT A & MARY JO RADINZEL RADINZEL, GRANT A & MARY JO
1417 47TH ST
HOULTON WI 54082
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 1417 47TH ST
SC 5432 SCH D OF SOMERSET
SP 1700 WITC
Legal Description: Acres: 12.360 Plat: N/A-NOT AVAILABLE
SEC 20 T30N R1 9W S 1/2 SE 1/4 LOT 4 OF Block/Condo Bldg:
CSM 3/811
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
20-30N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 708/357
07/23/1997 692/235
2004 SUMMARY Bill Fair Market Value: Assessed with:
5089 303,100
Valuations: Last Changed: 07/07/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 12.360 105,200 193,000 298,200 NO
Totals for 2004:
General Property 12.360 105,200 193,000 298,200
Woodland 0.000 0 0
Totals for 2003:
General Property 12.360 61,700 154,900 216,600
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
• S a N LAND .SURVEYING •
HUDSON , WISCONSIN 54016
(715) 386-2007
Name Rc.,.,.1 ' Ld, 1-2;. z^J t'~.~~;; r inc.
Address '7:.. r, 4. _ D16
Description o c> V<)1. S11 o recorded ii.,, the Cer-tli:_ied :~LLrvey
~s Oth (1, rer of i ed~;, aJi; l:Y"011> vOu1?i ~T~ <1
N
R=80 S 89°-52'-I4' W
707.42
111.96'
NOTE
LANDS LYING
SOUTHEASTERLY
R = 80.00' OF T141S LIME IS
C =83-36 ' F 3567, z WITHIN 1320' OF
CB = N 10°-13'-29"W .rte S31--30'-25"E o ST JOSEP41 TOWN
113.34' o° GARBAGE DUMP
W PROPERTY LINE
115:48 .a
W
~L
r1
im m
~m Q
1m N
,z m
LOT 4
Ln, 12:36 A.
o m
U D
Ni
L = 170-27'-47"
R = 791.78' r
C = 240.39' z
CB = S 61°-09'-56" E m
N
Irr W ~ N
U ,rj ` m
\ .gyp
\ S' 90
Z,
'66' TOWN ROAD \ `26:
- -
VALLEY VIEW TRAIL) ~C.
7.CR00(000TY
SURVEYOR'S RECORD
State of Wisconsin ) O IRON STAKES DRIVEN
County of _ST. CROI X ) ss. SCALE OF MAP - I INCH 204 Feet ® IRON STAKES FOUND I
I, ALLEN C. NYHAGEN , registered Wisconsin Land Surveyor,do hereby certify t
on AUGUST I 19 8o I surveyed the above described and mapped property occordin4l`
the official records and that the accompanying map is a correctly dimensioned representation to scale of the boundaries, thut
all buildings and improvements lie wholly within *0f"a"jnos, and that no encroachments by adjoining owners appear
from said survey. Z ~ ~"ma3 40
ALLa~' C.,'..
Mop No. 7 8 - 2 8 - 180 's { NYHACEN
:J
Drawn By D S S-1~'O7
HUDSON,
Boa
p I''C5? SU
Wisconsin Department of Industry,
I ;
PLB-1 INSPECTION REPORT Labor & Human Relations
Safety & Buildings Division
Bureau of Plumbing
Name o remises Date an No.
L '2
c+ss,~_ oun y Sanitary Permit-y'
as er Umber' Firm Name dress
v rJc-, rat T i t > - J / _
Journeyman PlumT37er -Address
Owner Address
r.. ..e~.,..... M P.. ...~.A A.
n
iscusse with ign ure
4 rr
( )See Attached.
DILHR-SBD-6192 (R. 1 1 /83) Signature o Dist. um i ng' °u-p-. 'Oh-Site waste p a T's'
Form STC- 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP SEC. T N-R W
ADDRESS ST. CROIX COUNTY, WISCONSIN
s
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of ILHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
JJ ~
/1llit>G
,fit l~
r,
..r- ' c
rs ~ I"
•vn
i
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: Proposed slope at site:
SEPTIC TANK: Manufacturer: 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 building:
SEE ce dimensions REVERSE SIDE septic tank)
(Include this information of the above plot plan)( 2 referen
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer:
Pump Size
Elevation of inlet: Bottom of tank elevation:
s
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:
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, Rear, O Ft./`
Number of feet from well: V-) 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: / „1r
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
MADISON, WI 53707 _
C CONVENTIONAL ❑ALTERNATIVE State Plan Number
(If ass,gned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE.
Grant A. Radinzel R. R. 1, St. Joseph, WI ',23 4_5 3
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.'. CST REF. IT ELEV.
SW SE, Section 20, T30N-R19W, Town of St.Joseph,Lot#4, Stout Addn.
Na- of Plumber. MP/MPRSW No Coumy. Sanitary Permit Number
Donavin Schmitt 3205 St. Croix 64839
SEPTIC TANK/HOLDING TANK:
MANUFACTURER . LIQUID CAPACITY . TANK INLET ELE V.. TANK OUTLET ELE V.. WARNING LABEL F~DING R
/ GG PROV DE
YES ❑ S NO
BEDDING: VENT DIA.. VENT MAT L.. HIGH WATER NUMBER OF ROAD: PROPERTY WELL. TO FRESH
J ALARM. LIN NLET.
FEET FROM
❑YES QNO ❑YES ❑hd0 NEAREST DOSING CHAMBER:
MANUFACTURER . BE DUING: I OUIO CAPACITY PUMP MODEL. =NUFACTURER WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED
❑YES ❑NOL ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING AIR NLOTRESH
(DIFFERENCE BETWEEN FEET FROM LINE
PUMP ON AND OFF) ❑YES ❑NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of lowin EDIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.) M
F
CONVENTIONAL SYSTEM:
WIDTH ILENGTH NO. OF DISTR. PIPE SPACING COV EH INSIDE CIA ttp1T5 ILIQUID
BED/TRENCH TRENCHES MATERIAL: PIT DEPTH
DIMENSIONS. j
GRAVEL DEPTH FILL DEPTH DISTH. PIPE DISTR. PIPE DISTR. PIPE MATERIAL. NO. DISTR NUMBER OF PROPERTY WELL. BUILDING: VENT TO FRESH
BELOW PIPES ABOVE COVER ELEV. LET ELEV. E D PIPE S: LINE'. AIR INLET:
FEET FROM 7d
T 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.
❑YES ❑NO
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCH: BED DEPTH OVER TRENCHBEU DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER EDGES
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
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 MANIFOLD MATERIAL NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING.
ELEV.. ELEV.. DIA. ELEV.' PIPES. DIA.:
ELEVATION AND
DISTRIBUTION
COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY
PLANS
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERS. OBSERVATION WELLS. NUMBER OF PROPERTY WELL. BUILDING.
FEET FROM LINE.
I ❑YES ❑NO ❑YES ❑NO NEAREST
0
11 !a l13S
Sketch System off-- a. _.f3eta my file for audit.
Reverse Side. U
I SIGNAT TITLE.
DILHR SBD 6710 (R. 01/82)
wisconsir. APPLICATION FOR SANITARY PERMIT
~ DILHR "y COUNTY
(PLB 67) UNIFORM SANITARY PERMIT #
QEPRRTTT1ErlT OF
- Ir10USTRV,LRBOR&HUMRn RELRTIOnS
-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
7 ZL R 5/i _ ,fl
PROPERTY LOCATION CITY:
VILLAGE:
76?1/4 . Z-1/4, S T C N, R / E (or ' OWN oF+ W- , Y .
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME EST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
f~r 1 f.
TYPE OF BUILDING OR USE SERVED
' 1 or 2 Family Number of Bedrooms: Public (Specify):
THIS PERMIT IS FOR A:
A 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.
V 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 Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity
Lift Pump/Siphon Chamber
Ma
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
i 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): Signa MP Sw o.: Phone Number:
Plumber's Address: Name of Designer:
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
~s C ❑ Owner Given Initial
~ 14, ~l Approved Adverse Determination
_jA
r
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
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 ('6~L,~'1 11: KA-D /t)
Location of Property I~ "s~ 31, Se tion n T 3n N - R W
Township
Mailing Address _ y7 juil),:- ' fj;-rj (L.~,,~7olf~ ~ MYj gZ
Subdivision Name L)rz1 ~F VQ`om' ,y0,e6 ~Zl ljs k~~i,2 P--I,> iNCtW7-
Lot Number
Previous Owner of Property
Total Size of Parcel
Date Parcel was Created ,a. (yam Ir
T
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume 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 ate statements on this 6oAm ane tAue to the but o6 my (ould
knowledge; that I (we) am (cute) the owneA(s) o6 the pAopenty descA bed in this
in6onmation 6o4m, by viAtue o6 a wahAanty deed AveoAded in the 066ice o the
County Re.g-ie.teA og Deeds as Document No. ~0tY,
and that I
pAesentty own the proposed site 6oA the sewage d.Lsposarbystem (oA I have
obtained an easement, to Aun with the above descAibed pAopehty, 6oA the
const&ucti.on o6 said system, and the same has been duty tecotded in the 066ice
o6 the County Regi4teA 06 Deeds, as Document No. ) .
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
- t4
VNJ - S T C 105 r
9
(y H
SEPTIC TANK MAINTENANCE AGREEMENT o
St. Croix County z
a
OWNER/BUYER E 7-
~~►A~'~~~ D~1J .FJ- ~
)3 2-'t2% N ze h
ROUTE/BOX NUMBER • Fire Number
CITY/STATE ZIP
PROPERTY LOCATION: i, 14, Section T _3,0 N, R21~--W,
Town of St. Croix County,
Subdivision Lot number/.
cT7474 .3 PgGC y1 / AS Ra!c-4UED iN fil Al's ~
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 um er. 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 aystems 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
to maintain the private sewage disposal system in accordance with x
H
the standards set forth, herein, as set by the Wisconsin Depart- ~o
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.
SICNED
t ~ I
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.
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ST. CROI X COUNTY
W1 SC O N S I N
ZONING OFFICE
796-2239 (HAMMOND)
425-8363 (RIVER FALLS)
HAMMOND, WI 54015
April 2, 1985
Mr. Grant A. Radinzel
13242 North 20th
Stillwater, MN 55082
Dear Mr. Radinzel:
Mr. Donavin Schmitt, the plumber you have retained to install the septic
system on the property located in the SW's of the SE'k of Section 20, T30N-
R19W, Town of St. Joseph, applied for your sanitary permit yesterday in
this office.
In conjunction with the building, etc. that you are doing, we would like
to make you aware that any filling and/or grading that you may do for
an access driveway to the property is a special exception use, St. Croix
County Zoning Ordinance, and would require a hearing before the Board of
Adjustment.
Enclosed please find the special exception form, along with a copy of
the St. Croix County Zoning Ordinance pertaining to filling and grading
in the Shoreland District.
Should you have any questions regarding this, please contact this office,
Or Mr. Dan Koich of the DNR,1621 Westgate Road, Eau Claire, WI 54701.
Mr. Koich's office telephone number is (715)836-2047.
Sincerely,_
Thomas C. Nelson
Assistant Zoning Administrator
TCN : mj
Enclosures
t • E H ' 115 R,'. /75
.
REPORT ON SOIL BORINGS AND PERCOLATION TESTS f• r
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
i P.O. BOX 309, MADISON, WISCONSIN 53701_.
s
L0CATION:Stur '/4, '/4, Section 2: Ljz N,R-al (or~ Cownship or Municipality ~J
L
Lot No. , Block No. ck -T7~kYL 44(d`A,, 4kw 1`&J 764111 County St'
/ (Vo ubdivlslon Name
Owner's/Buyers Name: _1Z tAO
P y
Mailing Address:_ 14ye- 'e- ' 16, 1`1411eeA 4140-11
TYPE OF OCCUPANCY: Residence X No. of Bedrooms COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW _X-REPLACEMENT ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS 7-3p_ -o--PERCOLATION TESTS__ T
SOIL MAP SHEET - _ NAME OF SOIL MAP UNIT Te ~1 RWed
_ PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES
9 NUM- RATE
NU INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTE INTERVAL
BER ® 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN~/IN
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SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,
NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK
o OBSERVED ESTIMATED HIGHEST / y~
IF OBSERVED IN INCHES /B- Q
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PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy A/
Indicate scale or distances.
Give horizontal andvertical ref rence points. Indicate slope. 4t-e19, 7-0 X,2-
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I, the undersigend, 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 location of test holes are correct to the best of my
knowledge and belief.
Name (print) r~' Certification No.
Address L S 0
Name of installer if known
Copy A -Local Authority CST Signatur
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