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Parcel 038-1119-90-000 01/25/2007 05:05 PM
PAGE 1 OF 1
Alt. Parcel M 29.31.18.4958 038 - TOWN OF STAR PRAIRIE
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 - JESS, DONALD A & MARILYN R
DONALD A & MARILYN R JESS
980 192ND AVE
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 988 192ND AVE
SC 5432 SOMERSET
SP 1700 WITC
Legal Description: Acres: 13.110 Plat: N/A-NOT AVAILABLE
SEC 29 T31 N R18W PT NE SE BEING LOT 3 OF Block/Condo Bldg:
CSM 10/2757 13.11 ACRES EXC THAT PT OF
LOT 3 LYING S OF APPLE RIVER AND WLY OF Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
THE EXT OF E LN LOT 2 29-31N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 1085/252 WD
07/23/1997 1079/59 QC
07/23/1997 891/447
07/23/1997 699/385
2006 SUMMARY Bill Fair Market Value: Assessed with:
175713 257,900
Valuations: Last Changed: 06/27/2006
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 13.110 70,100 157,800 227,900 NO 05
Totals for 2006:
General Property 13.110 70,100 157,800 227,900
Woodland 0.000 0 0
Totals for 2005:
General Property 13.110 70,100 152,500 222,600
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER C TOWNSHIP J~71,2^ Yu~ SEC. T ~N-RW
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE o
PLAN VIEW
Distances and dimensions to meet requirements of ILHR, 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
S. ' / NE
S fs /Lae ~~1 / '
6
S.T 74 wcl~ y
'2 ~Zxs~ v
sz' I
~8r
hm'44;
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used 211V - 2e-
Elevation of vertical reference point: /pO~p Proposed slope at site:
I
SEPTIC TANK: Manufacturer: ~CS Liquid Capacity: / OOd
Number of rings used: Q Tank manhole cover elevation:
Tank Inlet Elevation:- Tank Outlet Elevation:
~ feet
Number of feet from nearest Road: Front,O Side, Rear, 7 /00
~ feet
From nearest property line Front,~Side,O Rear, > /00
i
Number of feet from: well, building:' / 7
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUMP CHAMBER t'
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: 12- Length: S7 Number of Lines: Z Area Built:
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side,(aRear, O Ft.
Number of feet from well:
Number of feet from building: Z5-
(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: 1101
Dated: Plumber on job: r--
License Number: 7 sp~
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR
LABOR & HUMAN RELATIONS
P.O. POX 796? PRIVATE SEWAGE SYSTEMS SAFETY & BJDIVISI,
MADISON, WI 53707 ~y BUREAU OF PkiCONVENTIONAL ❑ALTERNATIVE Stale Plan l.D Number
❑ Holding Tank ❑ In-Ground Pressure Mound (If ass'gmK)
❑
NAME OF PERMIT HOLDER:
ADDRESS OF PERMIT HOLDER:
Richard Hadley INSPECTION DATE.
BENCH MARK (Perman 907 Coulee Road, Hudson, WI 3C)
enl reference pomtl DESCRIBE IF DIFFERENT FROM PLAN: ~ O J
NE -14 SE4, Section 29, T31N-R18W, Town of REF. PT. ELEV.: CST REF. PT_ ELEV.
Name If PIu,,,he„ Star Prairie
MP/MPRSW No. County
David B. Fogerty Sanita,y Perm., Number
3289 St. Croix 64849
SEPTIC TANK/HOLDING TANK:
MANUFACTURER.
/ I LIQUID CAPACITY: TANK INLET ELEV..
l// lJ} TANK OUTLET ELEV.. WARNING LABEL LOCKING VE
P OVI PROVIDE
BEDDING. VENT D A_ A ES ❑NO
VENT MATL. HIGH WATER ❑ NO
ALARM 1 NUMBER OF ROAD: PROPERTY WELL: BUILDING. VENT TO FRESH
❑YES O YE FEET FROM LIN AIR INLE
❑ Q~' NEAREST j cam` l
DOSING CHA gER;
MANUFACTURER. BEDDING. LIQUID CAPACITY PUMP MODE L.
PUMP/SIPHON MANUFACTURER
❑YES WARNING LABEL LOCKING COVER
❑NO PROVIDED PROVIDED.
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL ❑YES ❑NO ❑YES
(DIFFERENCE BETWEEN ❑NO
NUMBER OF PROPERTY WELL
PUMP ON AND OFF) NE BUILDING I VeNrTO FRESH
❑YES ❑NO FEET FROM AIRwLET
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing NEAREST
AREST
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE DIAMETER MATERIAL AND MARKING;
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM: MAIN
BED/TRENCH WIDTH LENGTH NO OF
DISTR. PIPE SPACING;. COVER
DIMENSIONS TRENCHES M qL NSIDE DIA #Plrs
PIT uoulD
GRAVEL DEPTJi FILL DEPTH DISTR. PIPF DISTR PIPE DISTR. PIPE MATERIAL. DEPTH.
BELOW PIPES ABOVE COVER ELEV. IF ELEV. END.
No TR NUMBER OF PROPERTY
~f r~ P S WELL BUILDING. VEN7 TO FRESH
C/. % FEET FROM LINE /l J S_ AIR wLET. V
/ NEAREST-~.
MOUND SYSTEM:
Mound site plowed perpendicular to slope
and furrows thrown upslope: Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
❑YES ❑NO meets the criteria for medium sand. TIONS MEASURED.
S~ ER TExruRE
PERMANENT MARKERS. OBSERVATION WELLS
-H TRENCH BED DEPTH OVER TRENCH;BED ❑YES ❑NO ❑YES
EDGES. DEPTH OF TOPSOIL. SODDED ❑ NO
SEEDED
MULCHED
'URIZED DISTRIBUTION SYSTEM: ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
3ED/TRENCH WIDTH LENGTH NO.OF
LATERAL SPACING. GRAVEL DEPTH BELOW PIPE
DIMENSIONS TRENCHES FILL DEPTH ABOVE COVER
MANIFOLD PUMP MANIFOLD
ELEV. ELEV.. DIA DISTR. PIPE MANIFOLD MATERIAL : NO. DISTR DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEVATION AND ELEV PIPES
DISTRIBUTION CIA
INFORMATION HOLE SIZE - HOLE SPACING DRILLED CORRECTLY
COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED
❑YES CC PLANS.
COMMENTS: PERMANENT MARKERS: ❑NO (7 ❑YES ❑N
. J~ OBSERVATION WELLS: -
NUMBER OF PROPERTY O
WELL: BUILDING
11 :
ED YES ❑ NO ❑ YES ❑ NO FEET FROM LINE:
L)vJ
Sketch System on
l y~~~
verse Side. Ret 'n in county file for audit.
SIGNATURE-.'~
TITLE
SBD 6710 (R. 01 /82)
i
77 Wisconsin APPLICATION FOR SANITARY PERMIT
DILHRy COUNTY
- oEPRRyMEnTOP (PLB 67) UNIFORM SANITARY PERMIT #
- InOUSTq V,LgBOR 6HUTRn REI.RTIOns ///r i//~
V 1
-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
r.C
PROP TY O NER MAILING ADDRESS
e?, 7
PROPERTY LOCATION CITY:
14556 1/4, S T N, R E (or OWN GE: ~C
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEARE AD AKE OR LANDMARK STATE PLAN I.D. NUMBER
J41
TYPE OF BUILDING OR USE SERVED
P/1 or 2 Family Number of Bedrooms. 3 ublic (Specify):
THIS PERMIT IS FOR A:
LJ 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.
J Seepage Bed ❑ Seepage Trench ❑ Seepage Pit El 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: iWe-f
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):
L 3 Private ❑ Joint ❑ Public
1, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
e of Plumber (Prinfly. ~ Si nature: MP/MPRSW NO.: Phone Number:
-x ('?y
Plumber's Address: Name of
A D ~.s! Z
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date:
❑ Disapproved
❑ 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
l
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.
s8~,~fl
APPLWAT LON FOR SANITARY L ERMLT
S T C - 100
This <ij)p!ication form i [o bu completed in full and signed by the owner the
pr,)jW1- y bcLng deve-toped. Any inadequacies will only result in delays of the permit
issuatu c. Should this dcvelupmunt be intended for rusale by owner/contractor, ("sly,
llwn a second k)rm shouLd be retaLned and completed when the property
1 I,ui!trkl fu !hi- I1 r
with thu
r
Own r ()t Property ''~C Fw4~~ A
Loc.+r Luu ot: Property S, ni-
~4 _ '4, Section
Tuwn s h i i) eA r.11~
MaiLinl; Address 907 %j1-
4 ~Ukj
Subd ivis i.on Name _
Lot Number jJ ~.~TES _ f30~)N►~~_ -
Prev i.ous Owner of Property ~O26WGF Z<)AAIDC'L
Total Size of Parcel
Date Parcel was Created
- x
nr, 1 i r anri
.i..
Is this property being developed for resale (spec house) ? - Yes es No
VoIu!ae and Page Number -3 QS as recorded with the Register of Deuck
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWLN,;:
1. Warranty Deed
2. Land Contract
3. Other recordings filed with the Register of Deeds Oflt(,~,
In addition, a certified survey, if available, would be helpful so J...
of the reviewing process. If the deed dese-ription references to a Cc
Map, the the Certified Survey Map shall also be required.
PROPERTY OWNER CERTIFICATION
'I Lj) ce.hti 6y .thcc;t at 6 ta:temert'4 on ,th" 6okm ah.e titue .io the bM t o6
knowX.edge; that ~ (we arl (ane) the owrtett(s) o6 the pnopetty de,6cAibed in .thca
~y ;!i t ti fi Nrj, Derr /
.y e
J 1„L'~Lc vw, iwvi. _iCi'i.%ty ile.eti ;1L'(.'.UILileCI. in 4.Yle 0Q6iCe. U6 the
(-ottrt ty Re9,i"5 teA o6 De.edti a,s Doc_umm t No. 3 9 7 S3 1 and that T (toe)
0'11-eaen,te-y own the. pnopo4e.d site.. 6oA the 4ewage r po,s~. system; (i IF (we) lrot
r j, 60P .the..
co,.s rust ore o6 sa, d 4ys.term, and the same ha~1 been duk'.ryryaeeoreded .in the 06oLee
o6 .0ic. Count y Re.gi6teA o6 Dee.A, ab Document No. 397 S,~ l ) .
.
iii ~t -
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SICNED
r
_ 9t- ISI
00 199
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`ITT IC TANc' PHA I N't FN ANCL A(:i:C:f.'tEN"I
St. CL i-x CuunlY
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tlu~rt./ t,~t;~ Nurtt;l-1~ ,07 _ c"' uc.eLwF i r N u 1, C.
1 I' 5101,
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I'kt!11FWiY LuCATION
Town ut St Crui CuunLY, I
tiubciiv Csion Luc It utit bc t- l'✓
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I'A l ~ [ U ll S cl l i ~t Ili c! 1 it C C I t : a n 1. ~ i I ~ ~ U r L "Iii ! : ~ ~ . 1 i _I ~ t'. S U 1 t 1 Il ~
L c tit it C U Z C .t it r e t u h n u . t't o) })i'r Illd 1 itt ctt,llit, e Cull -
i:,
;i:,L~ of puutpit?K oUt the SeptIC ait n curry tltrec yk+car:; ur suunCr ,
a i
tt neecied, t)y a iCc-eu5td sc•1)LLC Lank 1)uur)ur. lull -a t y o u 1) 11 it t o
Lllc' systtrlit ciao a Lt ct the tLk it C'L L', t1 01 tllc e1)L..ic. tit ii k it:; it treiat -
Ill r. II t- slit f:.e tt. Lhe wits Le d1 1) )5a1 y:_; tens
tit CtJiX L)it it Ly rCS idetala liter t, elit;il)le Cu reckivE a I;Cit it t Cur
it III Lip xilit. uIll- c)1 6U% u1 the Coat of repia CenlouL o1 it it 11; system,
wit ich w"AS Cu o1)cration prior- to July t, 1998. St. Croix County
acc:cl)tc(! LhLs I)rOgl-iittt iu AUu';Ilst ;)f 1.1)80, with the rt-cluircn1CnL tha C
owUr,z uC alt ucw sysCelit s it grce tc) keel) their systems; properly
u,r_t i n t_a i ned
Cltc~ 1) ruperty owner agrees to :,Li I)nii C to St_. Croix County l.oni -ng a
Crtiticatiu11 turns, sil;ncd 1) y thc owner .iitd by a utat,iter plLi lit ber,
loU rlleyntaIt piuIlk bCr, resLriCtc(A pIutit1) c r or it 1 eItsc(1 1)ulit1)er vcri-
tyinC t l.tat (-L) Cite on - site w LL sIt C.wJLur di5pe)sal syslulit is in propC;
uperLt tint; Cu 11 ditiolt and (2) aft Cr i11S1)CCtion and pulit I) ing (i_t neC
esrary), t Ile septic tank is less Chart I/3 toll of '-Judge a nd SCUIll
Certiticatioiii tuna will be cnt it 1) 1) r.oxiill it teiy 30 dzlys 1);:i0 r Co
thrue year expiration.
t/WE Ceti) undersigned, it ave read t itu a1,UVe Cr_yuireIll t.ni:6 ui:_, r,
to maintain Lite private sewage di.>posa L systcw in accordance with
the standards set tortIt, lie rein, as set by the Wisconsin Depart - lu
Inrtlt of Natural t:esourCes. Certificatfott Corm lit ust be CoIll l)leted
and returned to the St. t:roix County /.using OCficr wilIti11 30 dayti
of ttte three year expirat ioit dart=).
~ ,~/-yam
I C: 11 H' 1.)
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t)ATl:
St. C oix Coullty "Lolling Office
t' . 0 . C) x
Halit ill ottcl, W1 54015
715-7 16-2239 or 715-425-8363
Sign, date and retUrr? to above address
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DEi H ENT OF pb'RT N SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LAFjO'i; "ND 0 TION TESTS (115) P.O. BOX 7969
t-IUMAN RELATIONS ~,v \ / MADISON, WI 53707
9(1) & Chapter 145.045)
LOCATION: SECTION. m )MUNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME:
~I C '1456114
COUNTY: NNER'S UY $.NAME: MAILING ADDRESS:
l,Pc, D R 2rcf+~ A 907 Cou t_t:T. 'Koko u ~SoN kJ I• S"'~o /G
USE DATES OBSERVATIONS MADE
NO. BEDRMS. COMMER SCRIPTION _ PROFILE D RIP IONS: E LATION TESTS:
- FZesidence XNew ❑Replace I 2 16 So( L l;SooK 5C If L.S ; GoDZ GNET~K,_
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENT ZONAL: MOUND: IN-GROUNDPRESSURE: SYSTEM-INTILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
~ S []u a S MU T S ❑u S ZU 1 S Yu cNVENT(oN~r►- ►2'~ $W &a'>
P col„lion Tests are NOT re wired DESIGN RATE:
U III If any portion of the tested area is in the N ^
indei s,l'fi3.09(5)1f~), indicate: Cl...~SS 1. Flood plain, indicate Floodplain elevation: I"~
PROFILE DESCRIPTIONS
()PIN IOT.1,t_ DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
P-
r.tuMBER DEPIfi_ar ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
I .oo SN L w14 IC A O'. Z/ Qv 0-6 W
/a. ✓5-,(.0' M 1-'&E5r4S vvle--
B- IZ-23 84.9G N10tJE '7 !2• 3 4 o.oi' BANDS 17KBN MEDS; 0150'15140-Sw/6,e;5.oo'B~iMr.D5w/ z-
- 60' 8•ft_~o• O ~ti Me w G-r12,- 0.80• BN •S6, ,00'
B- 2 73o 53.32 f~0NE 77.30 BA CS W/ C_R. - ),a" ML-D w 4e
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PERCOLATION TESTS- tJUMBEQ Go~R.ES~NDS yv ~ :N A C-''~-~~=, I'.
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1 ESI DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MIN01 ES
-Ni INCHES AFTERS LI INTERVAL-MIN. -PERIOD 1 _ PERIOD2 P R D PER INCH
P. ¢ _7115C ONE .b
PLOT PLAN: Show locations of rcolatiodrn~_tCts, 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 Iqcation on the plot plan. Show the surface elevation at all borings and the direction and percent
oflandslope. IJ~; PAIL O, $M-rV4 aYV Or.IC7INAL.- ~44LSA REPI_ACSMF_WN7' *REA
WIi.L R.P.IlU.VtlLC YEri-it A "is FOR- jZCPj._AC_&Ai16NT S`'f:s7avV1
SYSTEM ELEVATION 86.5-0 g_,
L.ocATION K,c t-c+~ i s~ Z ,
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P~oAn KKG"T-OF-Wtt'r 1.INCZ~ -
h, undl rsi lned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in th;
,:Iiiwis,u,,tivc Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. 'T'ow S WE \"vl' r ntl ! TESf1
1,9135",
ON:
Lr~iirSS CERTIFICATION NUMBER: PHONE NUMRER(opt o ,i.' ~
¢d Ts
CST SIGNATURE:
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DISC RIBUT IG'N: l)iigin;tl and one copy to Loctii Authority, Property Owner and Soil Tester.
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