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Pw Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER I-e/l~ r, dJ, TOWNSHIP r b ~ SEC. J}~ T 30 N-R~W
ADDRESS z<~-e Z- ST. CROIX COUNTY, WISCONSIN
SUBDIVISION PIT LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H 63
SHOW EVERYTHING WITHIN 100 FEET OF SYS'T'EM
I
i
~ <„24
don r r ~G
f
y
J INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: Proposed slope at site:
SEPTIC T41NK: Manufacturer: %L2 Liquid Capacity: %Xb
Numbo'r of r:.ngs used: ! U lank -hole covet uievaLion:
Tank Inlet Llavation: Tank Outlet Elevation:
Number of f(:et from nez.rest Road: Front,O Side,0 Rear, O feet
From dearest property line Front, 0Side, 0Rear, 0 _ feet
Number of feet front: well building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUMP CHAMBER
Manufacturer: °f 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:
(Include distances on plot plan).
SOIL ABSORBTION SYSTEM
Bed: Trench:
Width: 5 Length: Number of Lines: _-2 Area Built:-6'-'Z)
Fill depth to top of pipe:
eyl/V
Number of feet from nearest property line: Front, O Side, O Rear, Ft. lG
Number of feet from well:
Number of feet from building: //D
(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 0 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:
I
Inspector:
Dated: ,7 Plumber on job:
License `Number : 3Z z~
3/84:mj
PUMP CHAMBER
Manufacturer: If 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, Q Side, O Rear, 0 Ft.
Number of feet from well: -
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORBT10N SYSTEM
Bed: Trench:
Width: :n Length: Number of Lines: Area Built:-6-
Fill depth to top of pipe: )
Number of feet from nearest property line: Front, O Side, O Rear,
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT
V
Number of pits: Diameter:
Size: /
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box Q 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:
~z/
~Y
LicensehNumber :
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUVAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969
BUREAU OF PLUMBING
MADISON, W.' 53707
N~ONVENTIONAL ❑ALTERNATIVE StatePl- I.DNumber
E] Holding Tank ❑ In-Ground Pressure ❑ Mound (If assigned)
NAME OF PERMIT HOLDER. [ADDRESS OF PERMIT HOLDERINSPE TION DATE
Jerry Luepke R. 2, Hudson, WI r-5r 8;GV /hJ
BENCH MARK W-anen[ reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.' CST REF. PT. ELEV..
SE SE, Section 36, T30N-R19W, Town ofSt. Joseph
Narn cif Plumber. MP/MPRSW N, County. Sanitary Permit Number.
Roger Timm 3224 St. Croix 64870
SEPTIC TANK/HOLDING TANK:
MANUFACTURER.,`` LIQUI 1APACITY. TANK INLET ELEV.. TANK OUT~ET ELEV.. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED.
i /~L• t a ~I DYES ONO DYES ONO
V
BEDDING. MATL. HIGH WATER NUMBER OR' ROAD: PR OP ER Ty WELL. BUILDING. VENT"TO FRESH
ALARM FEET FROM LINE AIR 1LET.
YES ❑ NO ❑ YES ❑ NO NEAREST Y
DOSING CHAMBER: r
MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL JPUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED: PROV IDED.
DYES ONO OYES ONO EYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING I VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM NE AIR INLE
PUMP ON AND OFF) EYES ONO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH DIAMETER 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.) MAIN
CONVENTIONAL SYSTEM:
I
NO. OF DISTR P E SPACING COVER JINSIDE DIA. tt PITS LIQUID
BED/TRENCH WIDT It 14 LEN T PIT
7REN ES. ( ! Mj//{rERI~A L', DEPTH.
DIMENSIONS i~ i`(
GRAVEL DEPTH FILL DEPT DISTR. PIPE, DISTR. PIPE DISTR. PIPE MATERIAL. NO. D R NUMBER OF PROPER Y WELL. 11,11-111\11 VENT TO FRESH
BELOW PIPES ABOVE VER F~~E V.I L i E~E V. END PIPESr LIIV 1 AIR•iN L6T
t ` I FEET FROM s r 1
NEAR EST--► y ; 41 I
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-
DYES ONO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
DYES ONO DYES ONO
DEPTH OVER TRENCHBED DEPTH OVER TRENCH;BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED.
CENTER EDGES.
DYES ONO DYES ONO DYES ONO
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
ELEVATION AND ELEV.. ELEV.. DIA. ELEV.. PIPES. DIA.;
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
DYES ONO DYES ONO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE,
DYES ONO DYES ONO NEAREST
..t
F
Sketch System on Retain in county file for audit.
Reverse Side.
$IG~ATUR E. TITLE.
DILHRSBD6710(R.01/82)x-
Wisconsin APPLICATION FOR SANITARY PERMIT
COUNTY
-1LHR`
(PLS 67) UNIFORM SANITARY PERMIT #
F:WLLM=W0AKt- mEnr ov
InOUSTRV, LROOR&HUMP" REL60 ] H 94)
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8,,x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER MAILING ADDRESS
7--
Z
PROPERTY LOCATION CtTY,:
V41:I=A^E:
J" 1/4 1/4, S , T N, R% (or) Tow S Jr~~e fj
LOT/NJ,JIyiBER BLOCK NM~BER SUBDIVIS~~NAME NEA~RE~T ROA ~ STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED /aj docu -c;to/6 _
1 or 2 Family Number of Bedrooms. ✓ [JPublic (Specify): fG~~
THIS PERMIT IS FOR A:
-1 New System Tank Replacement Repair
Replacement Soil Absorption System ❑ Revision ❑ Privy
rut Alternate System ❑ Reconnection Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM~OMPLETE THIS BLOCK.
I-
Seepage Bed Seepage Trench ❑ Seepage Pit L[ Holding Tank
El System-In-Fill ❑ In-Ground Pressure El Vault Privy ❑ Pit Privy
D Existing, For Which A Previous Permit Is On File, Permit # issued
r[ 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 t
Lift Pump Tank/Siphon Chamber -47
Holding Tank capacity
Manufacturer:
i
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):
<.3 ~Y r v~ 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): Signat e: fMPRSW No.: phone Number:
Plumb is Address: Name of{?e9+c3ner:
po 7c, _Z
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee. Date: ❑ Disapproved
( '7~ ❑ Owner Given Initial
L " l.' 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.
AL'111-ACAT ION FOk SAN LTARY PERMIT
S 'i' C - L M"i
zt1,1)s il-.at-io)u form i:; complett~d in !-Lit] and signed by th,~ owne,r(s) of Lite
propcrt.:, being; developed. Auv inadequacies will only result in delays of tE,e uermit
issu:)rnc~. Should this dL,v,,lopment be intended for resale by owocr/contractor,("spec
ho user";, then a second Iona sLouLd be retained and Completed whUn Lite property is
Ci"j to t t Js ' ! til Cht~
_1i _ Cvl cii,(~"t)i5~iate: t1C!'d )r
Owner of Property
Luciuti Property SP_Cti,u , T c'_r N - k W
Towu,-0hip c~77 j ~ r
MailiuL; Address
T_ j: I
Subd[vision Nance -
Lot Number ✓~14~ AI
Previous Owner of Property
Total Size of
Parcel
Date Parcel was Created
Are all corners and lot lines identifiabie? Yes r~o
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 APP1.iCAC10N ONE OF THL: N'01.1,OWIN
i. Warranty Deed
2. Land Contract
3. Other recordings tiled with the Regi:~tez ok- Deeds 01ii_cc
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) ce4ti6y that att statements on ,th,i6 6onm ane VLue to the best o6 my (ou,n)
know-Ledge; that I (we) am (aAe) the owneA (a) o6 the pnopenty dan- bed in -th'IE6
in6ohmat&)ft holm, by vi&t.ue o6 a waAnanty deed neeonded in the 0664-ce o6 the
County Regi,6,ten 66 Deed,5 as Document No. 3;1'7 ; and that 1 (we)
pneaentt,y own the proposed site. bon the bewage dzpoia.e eya-tem (on I (we) have
ob-ta, ned ait easement, to nun wi=th the above descAibed pnapeAty, 6oL the
cons.t'cuc,t. on o6 6aid 5 yd tem, and the batne_ had been duty t ecugde.d -in the 066iee
o6 the County Reg-i~s-teA o6 Deeds, Document No. )
SIG ATURE GF-OWN1;1? SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
S `r c - I07
Y
SEPTIC 'l'ANIy MAIN'LLNANCLI ACRELI'H';N'f C'
fit. t.:ruix t;ouuCy
Y
I' 1 'I"s /.;'I ATE:
1 P L; It't Y L 0 CA F I (1 Ci ~P fit. , ;~a~ 5 t lull _ w
1'uwn of'T ~ca`~^1^t'_ St_ Croix County,
Lot uutit ber-~~_ F~.
u~t,cuse dII,t waIll trn,_I111* su1)L I Cclit list rC!:ult- in
t'tu )qtr iila LnLuttal C C Culi-
its preIll ature'laiiif ra. to ilciudlc wa_;Lctn-
t;1SLof pufit ptut; ouL tSu1~t.LC tank 12vury three yeit rs or soouer,
I
it needed, by a I > eIi se d Sc1)L is taitk L)um1)L'I W11at YOU pul iutu
LIIe Sy5tN.Ill C a I I ,I, CCU the tkill CLi01i of the C1) C tank ait treat -
ulcnt s tai;e in the waste di st,osaI system
SL Croix County resident.; Ina~; t) L2 c:iit iL,l~~ t_u rucuivC a rct11L iur
a Ill Li xiill uIll of 60Z 01 the cost of r~plaCel cIlL of it lail.inb Sy Sten?,
which was in opernC.ion prior Lo July 1, 1916 . St. CruLx County
A( CC1)1cd this prui;ram iii Au~,ust of 1980, with Ukc r(:duiroIli cit L tlk;it
u~.ouers of aL uc w sysCeit is tal;rc~e to keep thr~ir systems properly
w~1 i utai11 ed.
the property owuur agIeeS Lk SublitiL to St. CrUix CUnty Zo11i11~ a
Cc17L fiCati0n torfit sik;LIod by th1~ uwitcr and by it master plumber,
-juurit eyIll a11 plumber, rests iCtud pi.UIll 1)k2r qtr it I iceit se,d pumper vuri-
fyi11g that (1) tale on- Site vi aLi Lew :tcr disposal sysLetit is in proper
operatini; Condit Lou aIt d it itur inS pccLion and puIll pi11g (it nee
essary), t he septic tank is less Chun L/3 tt.tll of sludge and scum.
Certification Lorin w1-11 be r;etit approximately 30 days prior to
rJ
three year expiration. c>
I/WB, the uii dersiiit ed, have read tkte above r- eyuireulentS a nd agrce
~r.
to maintain the private sewai;c d i sposal_ cyst cam ill accordance with r
the standards set forth, hurein, as set by the Wisconsin Depart- a
ment of Natural Itesourees. CerLif ic;itiott brut must be Coin l;Leted
and returned to the. St. Croix Coclnty Zouini; 0ttice within 30 days ~I
of the tkiree. year expiratioii date.
l
S ICNF - ;i
L: A (i - y -
St. C oix County `Lontni; 'Ofticc
P.O. ,lox 9E
Hammo'j~d, WI 54015
715-716-2239 or 715-425-8363
Sign, slate and return to above address.
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I)PPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & E3111lDIN
INDUSTRY,
DIVISION
N ~
LABOR AND PERCOLATION TESTS (115) MADISP.O. BOX ON WI 7969
HUMAN RELATIONS
(H63.090) & Chapter 145.045)
LnC/1fION SECTION: OWN iQTCISrRCi'Y: LOTNO•:BLK.NO. SUBDIVISION NAME:
5E 145 E1/4 ~ /T3o N/Ri9 t) 5T..10 5&PN -
COUNTY: N UWAE4W6 NAME: MAILING ADDRESS:
USE _ DATES OBSERVATIONS MADE
g Residence B DBMS.: COMM R l DDESCRIPTION: RO L IP IONS: A N TESTS:
LLVResidence A/ Od p I
L- 0New Re lace. / ~q /L2 Z~~~
Sv ~L. ao 3 LA T- gooier P, ¢i E14fC..'ti; SUEKNlI~DT`/ ~X~z
RATING: S- Site suitable for system U= Site unsuitable for system
T❑~L:Mw~. DU IN G~~ P❑U RE: SY~EM-IN~-FILLH~I ~PJG TAU CoN'`1C 1~lTf c~n/h-t..pt ~z I) X ~9,('~~"d
It Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: L_ Flood
N+4, t~1r~i?::~ plain, indicate Floodplainelevation:N,~r S~NGB Np4N
EGINy~tr PROFILE DESCRIPTIONS
BORING TOTAL P H R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH"% ELEVATION OBSERVED I HE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BFI.'':K.)
JO ~ /.ov QL t. ~ 1./v• r3N L w c.a.+,w~o~,~ I~Etprvn,~,
B- j /o•ov X78.31 l1IoNM
D(SrrMc-T ftior; o,Ga P.o 8.j LS w/40% (511t;
30' Br./ eS W //O% C7A. W oCdAS,o,VAC.
B- 5it-7 r3AL_L_s
B- _7 9.~0 7.4-4 /go/Jc= > x,60 /,&c)' s,,j S;L; i.ov- 3., LS w/ ioi,, c--•~e.; z.va' 84
CS W140 ,+o -t od ' M 4!~D S
t3A os o 9 k• Q,.r. f/i QL0 a
B-
B- 3 g,ool y~.4S h/OI~E > g,o0, 0, 60' FSL l,ao' B,r o' ►.l ;s.0 o'
B- ~hNOS of K• g/✓. f.I4EO
6UM^t_ PERCOLATION TESTS
FE ST
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER -tfaCrlrS AFTERSWELUNG INTERVAL-MIN. p' f~l:~e i p PER INCH
P- 4 t1 on/E 98.
P- 3,03 W16 97. (a 3 y d 3
P ,r0 O Z 9131 f0
P_ ps r
P- L.cJ
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 hon
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.
Loci-T-r o~.1
SYSTEM ELEVATION _ 34, o0 r4
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1, 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 : PESTS WER MPL TED ON:
A4 CE"S
ADDRES : CERTIFICATION NUMBER: PHO E NUMBER(ophonal):
S-r o~~►N t oih 71t 3 L16--46'9 (j
CS I G~~N__ ,U~~R~~E..
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. F~
JOB L- Lac j~
ROHL & TIMM EXCAVATING SHEET NO. OF z
310 Arch Street
HUDSON, WIS. 54016 CALCULATED BY ✓ rJl r7 DATE
(715) 386-8664 f _
CHECKED BY DATE
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SCALE
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r
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PRODUCT 2041 ~~e~1,c G,Ao, Mass. 01471.
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ROHL & TIMM EXCAVATING
310 Arch Street SHEET NO. OF 2
HUDSON, WIS. 54016 CALCULATED By pt' DATE _ ✓
(715) 386-8664
CHECKED BY SCALE
vZ's'L ~ T I Yt _
4
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/15
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PRODUCT 2041 Z ~Im, Groton, Mass 01471