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HomeMy WebLinkAbout040-1069-30-200 n N O K v n d r- 3 ' :3 CD 3 m ` 1 CD 3 Cl) -4 0 y O N v, O oo O -4 41 p cn CD 3 o c OD N "o c- : Z d 1 ry7 N_ j p "h \ CD W CD O co W O ^ (D 7 0 W ^ O -0 0 (D :1 a O 7 y W w N) CD O O l~ O n cn 9 m (n D m a 0 P rC n m o CD (n a < U) W CD ~d 0 CL CD c) 3 O a b r-r (D H. rl N (D m o n r cn CD 00 00 (n a ~ F'3 U) U1 En _ 0 CS , 4-- Un C..~, 00 00 O Z O O O tr H n' ID c cn ti N D CD y A U) n O CCD (D CD m -0 L (D = m r r , 7 3 d (D m r't ~ _ Jo N Z co Z O ti `O r\ O D 0 O CL 00 ^1 J CD ID y 0 C07 ONO (DD a) Ul (a z c (D CD O W Cp [1 CL 3 7 Z CD Z CD vF,, (D O O A O x+ C1 ~ C ~ ~ .r N- 9 Q III A 7 (D 0 n 03 v m N v N 2 i t Z 3 A 0 K - 0 o H ~ ~ w m CD CD O v 0 c D 3 CD C CD 7 n 0 Q G m°x. 0 c 7 0 fy C CJ CC'n (a z p, CD CD O_ pp CD CD 7 p N 7 aa~ ~ a CD 7 a m (D o M < CD Cp 7 O E-L m o o ao CD it 3 VCOv (D ' :E ti (n O (D O a A 0 b O_ p N O ~O O \ ti CD (D ~y + Parcel 040-1069-30-200 05/02/2005 05:01 PM PAGE 1 OF 1 Alt. Parcel 17.28.19.264B-20 040 - TOWN OF TROY 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 WERNER, KEITH S KEITH S WERNER RESZKA DIANE RESZKA DIANE J 433 E COVE RD HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description * 433 E COVE RD SC 4893 SCH D OF RIVER FALLS SP 0100 CHIP VALLEY VOTECH V11- Legal Description: Acres: 13.346 Plat: 1158-CSM 14/3970 SEC 17 T28N R19W NE SW BEING LOT 1 CSM Block/Condo Bldg: LOT 1 14/3970 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 17-28N-19W NE SW Notes: Parcel History: Date Doc # Vol/Page Type 06/07/2002 681219 1906/628 WD 07/23/1997 1183/234 PR 07/23/1997 883/01 2004 SUMMARY Bill Fair Market Value: Assessed with: 26675 319,000 Valuations: Last Changed: 07/20/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 13.346 110,000 209,600 319,600 NO Totals for 2004: General Property 13.346 110,000 209,600 319,600 Woodland 0.000 0 0 Totals for 2003: General Property 13.346 100,000 199,200 299,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch 131 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel 040-1069-30-200 10/02/2006 08:11 AM PAGE 1 OF 1 Alt. Parcel 17.28.19.264B-20 040 - TOWN OF TROY 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 KEITH S WERNER O - WERNER, KEITH S RESZKA DIANE C - RESZKA DIANE 433 E COVE RD HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description 433 E COVE RD SC 4893 RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 13.346 Plat: 3970-CSM 14/3970 SEC 17 T28N R19W NE SW BEING LOT 1 CSM Block/Condo Bldg: LOT 1 14/3970 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 17-28N-19W NE SW Notes: Parcel History: Date Doc # Vol/Page Type 06/07/2002 681219 1906/628 WD 07/23/1997 1183/234 PR 07/23/1997 883/01 2006 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/20/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 13.346 110,000 209,600 319,600 NO Totals for 2006: General Property 13.346 110,000 209,600 319,600 Woodland 0.000 0 0 Totals for 2005: General Property 13.346 110,000 209,600 319,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch 131 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 'L z) TOWNSHIP rc9 SEC. i •7 T vZ S N-R ADDRESS 4+g4) ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT ~,/C► LOT SIZE PLAN VIEW D_stances and dimensions to meet requirements of ILH•R 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM i 1 f I INDICATE NORTH ARROW BENNCCH,MARK: Describe the vertical reference point used I f~~cd'~ ~cac~~'= Elevation of vertical reference point: I p©,zm Proposed slope at site: -,P;~~_ SEPTIC TANK: Manufacturer: CJt~ [ .c,6 ,~~Liquid Capacity: Number of rings used: .,2~ Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,O Side ,0 Rear, O feet From nearest property line : Front,0 Side,0 Rear, O feet Number of feet from: well , 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, 0 Ft. Number of feet from well: v Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench.: Width: ` !7 Length: Number of Lines: Area Built: Fill depth to top of pipe: Number of feet from nearest property line: Front, eside, O Rear, 0Irt. Number of feet from well: h 7 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, 0 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 DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION MADISON, WI 1,3707 BUREAU OF PLUMBING XX)CONVENTIONAL ❑ALTERNATIVE State Plan LD. Number Ilf assigned) Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE. Herbert Day N. Cove Road, Hudson, WI 7.~~~" BENCH MARK (Permanent reference pomti DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT ELEV.. NW SW, Section 17, T28N-R19W, Town of Troy Name of Plumber: MP/MPRSW No.. County Sanitary Permit Number. Henry Nechville 3258 St. Croix 64882 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER PROVIDED-. PROVIDED. OYES ONO DYES ONO BEDDING: VENT DIA.. VENT MATL. HIGH WATER _ NUMBER OF ROAD. PROPERTY WELL. BUILDING: JVENT TO FRESH ALARM I FEET FROM LINE. AIR INLET. OYES ONO OYES ONO NEAREST DOSING CHAMBER: MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVDED. DYES ONO EYES ONO EYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL BUILDING (VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET' PUMP ON AND OFF) EYES ONO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing Nr;TH 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: WIDTH LENGTH. NO. OF DISTR. PIPE SPACING. COV BED/TRENCH M INSIDE DIA cPlrs LIQUID TRENCHES DIMENSIONS ( PIT DEPTH GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MA ERIAL. NO. DIST NUMBER OF PROPERTY WELL. BUILDING. [AIR ENT TO FRESH BELOW. E ) ABOVE COVER. ELEV INLET EL,EV END. G PIPES / LI INLET : / 7'~ FEET FROM ~E 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- O YES ONO meets the criteria for medium sand. 'IONS MEASURED. SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS DYES ONO DYES ONO DEPTH OVER TRENCH;BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED. CENTER EDGES. OYES ONO EYES ENO EYES ONO PRESSURIZED DISTRIBUTION SYSTEM: BE WIDTH LENGTH NO. OF 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. DI AA DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING ORI LLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS EYES ONO DYES LINO -1 1 COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING. 0F/") LINE: FEET FROM C OYES ONO OYES ONO NEAREST- 7y a S tch Sys on Retain in county file for audit. Reverse Side. SIGNATURE. TITLE. DILHR SBD 6710 (R. 01/82) ~M wlsconsln APPLICATION FOR SANITARY PERMIT COUNTY DILHR nOUSTRY,L ORBOR 6 HUmgn RElgTI ~Y (PLB 67) - f inOUSTgV, T F 10 UNIF M SAN R PE MIT # OnS III / -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 PROP RTY OWNER MAILING ADDRESS PROP 6'-F PROPERTY LOCATION CITY: tV 1/4 401/4, S / 7 , T; 2N N, R /i' E (D VILLAGE: LOT N B R JBCJ, BER SUBDIVI~ NAME ROAD NEA LA E OR LANDMARK STATE P A I.D. NUMBER r C_~ E% cIL TYPE OF BUILDING OR USE SERVED O /D~ ICJ CiL/~ D!~ 7 or 2 Family Number of Bedrooms: Public (Specify): THIS PERMIT IS FOR A: ❑ New System ❑ Tank Replacement ❑ Repair u"eplacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. L~ 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 c' , c Holding Tank capacity Manufacturer: 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): ,ate ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Nam of Plumber (Print): pSign re: MP RS o.: Phone Number: 4 13- Plumber's ddress: Name of Designer: /fQ l `c ~T Cif COUNTY/DEPARTMENT USE ONLY Signature f Issuing Agent: Fee: Date: ❑ Disapproved Q' ❑ Owner Given Initial ~•et/ / ~9 O s 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 two"il any rep ritona in the Wis. Adm. Code will he. 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. Form - S `I' C 100 Owner of Property f! 6 C!~ a Location of Property //,C $ ~4, Section, i' ~N Kj~ l Township Mailing Address-,L. --/1'' cl~~ n/j/ Subdivision Name Lot Number Previous Owner of Pro ert P Y_~G~u, rc+" ccty Total Size of Parcel `7 Date Parcel Was Created Are all corners identifiable? Yes No Include with this application one of the following: .Certified Survey Map .Deed .Land Contract, or .Other I;egal Document which describes the property PROPERTY OWNER CERTIFICATION i I (We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No. 3 cs~ ; and that I (we) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of the County Register of Deeds, as Document No. SIGNATURE O OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) r _ DATE SIGNED DATE SIGNED H H } ST C- 105 r r • a SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County z d a OWNER/BUYER / H r ROUTE/BOX NUMBERS Fire Number • CITY/STATE_c;~/L/ 'LIP ~'~Cnl PROPERTY LOCATION: `U,' 4, 5 Q,/__-'4, Section, Ts N, R l~ C, Town of 7- -"+V St. Croix County, Subdivision./ Lot number. 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. 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. H 0 I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with x 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 G DATE St. Croix County Zoning Office P.O. Box 98 Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. v ' ° to x m x y 4 1p y` W 7 C C N 3 0 d+ O co SW > 71 a0 ~ 110 o c O N w= 3 0 0 w phi Z' O O 0 fail CD cD -0 a CD (D O O= ~ H A Ip a 0 n pp~ = O N O N yi W p CD O (O C O W ~wao 9fCDCL ~ W ID C-) a O n o= S Co P omY c ~co~w o co m = ° o 3 ° c C- c _ c c r. 2 cc l< c CD w A) ai _-r I cn - W co o a am. m 3 D (D Co " 'a 'a <mcn Q~mc"o co Q o CD Cn C 'n o°~ 0 Dc~cD4~, c - n O wma oCD of CD co 0* a Q W 0 co CD 0 0) c New (n f o :1 co D i vi m CD w n = S (CD ? a (D 3 CD (D a oja o~g~0» D aNm ?W?C~o ITi ~a ?2) F N ~ O ac 0 :E CD ~ m 3 cm 0 CD M C fTi ~ cn a°, a CD CO SJ 0 CL Co 0 (D 60 to ° - w t0 D A) CD 0 (a , CD 0 0 (n ~J "i aof a a,cc°awo ITi won ao 9 aaa`Da-o c C U) -4 y < Q O U1 0 0 C `G fp w ? lD aoc ~o cc ~a o070mo c CL. c (y -Ci m (D C CD ~m 7 w a_3' c aCD o 3 ~Q3 c~TD a ° < o CD ~o ;T(Vlq NT OF & BUILDINGS .,OUSTRY, REPORT ON SOIL BORINGS AND SAFETY LABOR AND DIVISION HUMAN REL4TIONS PERCOLATION TESTS 115) P.O. BOX 7969 4 (H63.09(1) & Chapter 145.045) MADISON, WI 53707 LOCATION: SECTION: N10 ~ 17 /TLAN/R/?r (o TOWN~o~Dn, L~O)T NO.: BLK. NO.: SUBDIVISION NAME: COUNTY: OWNER'S R'S NAME: 4%'e f fy¢~ j/ ~f€~~F~ ~ MAILING ADDRESS: / ~ S' 40/- ' T 1 USE //IJ,4p5-&,j &)4f NO, BEDRMS.: COMMERCIAL DESCRIPTION: DATES OBSERVATIONS MADE Residence ~J PROFILE DESCRIPTIONS: PERCOLATION TESTS: ❑New Replace RATING: S= Site suitable for system U= Site unsuitable for system S~ S%/f /Q,4y 4)/ X,44,0 ,SO/1~ - S" 7;e CONVENTIONAL: MOUND: IIV-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:(optional) s sou os lu ©s ❑u EIS ou ❑s au o,~~01111,o,0~ ~oA,0 7A If Percolation Tests are NOT required DESIGN RATE: under s.H63.09(5)(b), indicate: G'G/f SS~ If any portion of the tested area is in the Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS 1N ~7tcj,tL NUMBER DEPTH IN, ELEVATION BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER O: 1 SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- / D 93.0 .7 -,c-, Am.51 /./7'Q s . v /Y~. d' C' S /d O 90 7- > v ' 7S '4.4- 313. s;/ i zS a . , d B-2- 7V 4M c°s B ~iXf6ti_~ B- e^ PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME NUMBER INCHES AFTERS ATER N HOLE INTERVAL-MIN. DROP IN WATER LEVEL-INCHES eN PERIOD 1 PERIOD 2 ` RATE MINUTES P- / PERI L f / PER INCH P P- .0 Z P- • ,s 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- of land slope. 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 SYSTEM ELEVATION = ~7 ~p moTE -USE' Tka/ f r , A-L"'- ~~lJ 4-041y 70 ~A/N T,+; v fx ! s ri,a G• G.P,1DF- , /(IO,r - f iE 40 ~QtZg L 60 az I , i ° ScALE E 1' Zd ' 1 x` 32 ~ 10--+ ~N dcX157146. 3 I X ccK, S 7-1A) 6- . f wti/ c,~Si46- 4 Fx ~'~~U~TioJ = 0 f. ,oo . I, 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 (printl: ~Q R~rF ~ r7 /L R p ('C ~ TESTS WERE COMPLETED ON: '~l f~ f` ~'1 ADDRESS: Z Z - ~ F~~ J L ~D, U~SD~ /-r~ ~s. CER1IFICATION NUMBER: PHONE NUMBER(optional): KJ 15 S = o Z y~ 3P 6 - S7'61P CST SI NATURE: )ISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. )ILHR-SBD-6395 (R. 02/82) -OVER Y ~ $i1 9 $U 3 P a ..v k'$Y *s $ L -.d'4..d drY o-. X k • ` ff 4 Ci tf€ 9 %1 4 (}t't,}' i"s5l uC:i;t}r l `;415; 3 1 lAXiM um rliun) 0, o i1~' tt Cin" i ? lit 34 7 i1 to I- _ .,.1 °L lo ~"s L1 ~ ~~p ,svt.~. l ~ `.~irl~p tip t y„.< ta• ~ t (f)~l ]''4r 7 pi Ci, ` 30d p P s., .r? tir aii; ~S :.,tp to F A `'?E. o }a ai-A) i - p i EEf a7'1.r, i.3t ~.f5t't2 )_;c~;-C~y 4 rp t fiail.v1 o pmi't red v ~huvvn' and ~p gt ds~ pr e„td'. as a(l di?les nanw",r c8 5-,: tooo pkiir, data, * s xy3 p t F }ate ~ { ~7 (tS,ce. Ni. ,p t ~i's F 34 < ~ titi cep~ ~ t~G t 1~.S~1 C° ?t _ t~~„~'~ p7€ 1(l tt} LcY6PC3f}~ f~a3-a t t addtes, :in t,Y F p l t.;<, It t lta li}x p _ f tTt 23 3 a C t l t E~ jj 5- P} Y t n~;t f z~ t?f' V, l TESTS ile... ~.e 1. E. P1, E TI ()N - n B , ii'. - md, • .2'~ US P . 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