HomeMy WebLinkAbout040-1119-40-000
<n o 3 o tz
B '4.
v I v CD
3 #
CD 0) 1 w o •
C] p~ O m O ~O O O O C'
< N j
3 m m CD
(D Zo
CL z
co co C CD
° co
v
M 1
N N 0
O- O O O N A O
O =
O fD O "p D O
U1 co O r. ~1
D N 3 0
N C ~ I ~
w to D a
(D (n CL
A
M O j rn T
(D ~ 4 O
(D CD
O C N•
CD CC) Cl) m~ T Cl)
rT
Z
0 = p v
cn v> to o
v
CD Q O N w
O W O
7 O7 y D N
C1 V)
N CD
z
o C -1 z
m
77 7
v O
o D
?
0 CD
> > N 0
(D
0 v
m CD ~
N
C
O N
CC 0-
W
(D
Z p Z_ N
O N 51
A Z
v Cl
3 (n --i Ca
co m m N
(D 00
z
1 3 a
0 _
Z
o
N Z g
CD
A
C.J I
C/)C 3 Q
< fn' Q
ZZ
< p~ T
~ n N C
CD z o
0 0
(D m
N
_d
0 H
CD .a
o ~
o
CD
rt
o ~
S o-
A R
O b
N
n N
(D O
N O
A
~ ^ I
O b ti
:3 Z
N b
N
Efl O r Fyn
O (D
y
O fl_
Parcel 040-1119-40-000 11/05/2004 10:31 AM
PAGE 1 OF 1
Alt. Parcel 31.28.19.487A 040 - TOWN OF TROY
Current XlI ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units
00 0
Tax Address: Owner(s): Current Owner
EASTON, JENNIFER N & HEATHERS
JENNIFER N & HEATHERS EASTON
74 CTY RD F % i - -
WI 54022
Districts: SC = School SP = Special Property Address(es): = Primary
Type Dist # Description * 74 CTY RD F
SC 4893 SCH D OF RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
J
A
7
Legal Description: Acres- ~ X32.845 Plat: N/A-NO AVAILABLE
SEC 31 T28N R19W SE NW EXC HWY AND~E :D Block/Condo Bldg:
PARCEL 4 2 INC PT OF
1 CSM 6/1567 ESC AS COM N1 4 COR Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
DEG W 1679.75'POB; TH S 31-28N-19W
1 DEG X54'; H N 88 DEG W 361'; TH S
1 DEG W 361'; TH S 88 DEG E 361'; TH S 1
more...
Notes: Djv l/q of N l7~ Parcel History:
Date Doc # Vol/Page Type
11/26/2001 663145 1772/105 EZ
07/23/1997 1128/303 WD
07/23/1997 908/294
07/23/1997 728/437
more...
2004 SUMMARY Bill Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 07/21/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 7.015 82,500 233,100 315,600 NO
AGRICULTURAL G4 25.830 5,000 0 5,000 NO
Totals for 2004:
General Property 32.845 87,500 233,100 320,600
Woodland 0.000 0 0
Totals for 2003:
General Property 32.845 68,300 234,900 303,200
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
Parcel 040-1119-30-000 11/09/2004 11:10 AM
PAGE 1 OF 1
Alt. Parcel 31.28.19.486 040 - TOWN OF TROY
Current XI, ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units
00 0
Tax Address: Owner(s): * = Current Owner
EASTON, JENNIFER N & HEATHERS
JENNIFER N & HEATHER S EASTON
74 CTY RD F
RIVER FALLS WI 54022
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description
SC 4893 SCH D OF RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE
SEC 31 T28N R1 9W 40 AC SW NW Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
31-28N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 908/294
07/23/1997 728/437
07/23/1997 700/30
06/18/1997 1246/339 WD
more...
2004 SUMMARY Bill Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 07/21/2004
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 40.000 2,700 0 2,700 NO
Totals for 2004:
General Property 40.000 2,700 0 2,700
Woodland 0.000 0 0
Totals for 2003:
General Property 40.000 2,800 0 2,800
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
10
m
m
M I
~lj 00
~ 3
484 B 4$4 C i
V 309 8.
-41
NC/AJU j
,X V p' 21,
SE //4 - NW 4 6I g6~
~
VO\ i G` N
P.~ N
r. i~6'~
LOT 1 4
487 A M 487 B%
OD v~
N 36
500 N C.
1i , a
(I I
462.61
a !
LOT 1
V% ~odl1.
C. S. M. VOL. 8, PG, 2223
487A 10 c6
tD
s' N
557.36'
-77
A S B U I L T
. ~ C-0UN TY
.~:ner's name Towns ip/Municipality Sanitary Permit No.
Show :
Q Location of building served Dosing chamber
1--7 Septic tank./Manufacturer ~,t' z,~ ! Vertical/horizontal reference point
[ Building sewer System elevation is.
J~ Effluent system Well
I Replacement system area Property lines w/in 50' of system
} Distribution boxes Scale or dimensioned
Pump and controls: _
Mfr, & Model No. Vertical Lift Size Force Main
Friction Loss T. D. H. Vol. Dist. Pipe Gal, per Min. Gal. per Cycle
Elevations: Distribution Pipe:_
Inlet Outlet Manhole Inlet End
Place check mark in appropriate box, indicating item is shown on as built below:
~ /~~4tUCr
i
U/
I~
0
Plumber's Sianature License No. Date
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 759 BUREAU OF PLUMBING
MADISOI\,, WI 53767 k7 CONVENTIONAL ❑ALTERNATIVE State Plan l.D. Nurnber.
(If assigned)
❑ Holding Tank El In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER. JADDRESS OF PERMIT HOLDER. INSPECTION DATE.
Joe Persico 507 E. Elm St., River Falls, WI 54022 30
BENCH MARK (Permanent reference Point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.. CST REF. PT. ELEV
SE NW, Section 31, T28N-R19W, Town of Troy
Na-- of Plumber jMP,MPRSW Nr, C~u ,t Sen,,F
v v Per-! Number
Eugene Grove 5569 I St. Croix 64909
I
SEPTIC TANK/HOLDING TANK: _
MANUFACTURER LIQUID CAPACITY TANK INLET ELEV. TANK OUTLET ELEV IWARNING LABEL LOCKING COVER
T - IP O DED PROVIDED. ~~y~(L YES ❑NO ❑YES L-1NO
BEDDING: VENT DIA.. VENT MATt HIGH WATER INEARESTROM MBER OF ROAD PROP ER TV WELL. BUILDING VENT TO FRESH
JALAHIM LINE AIR INLET
❑ YES O C - _j FEET F j
YES ❑ NO
DOSING CHAMBER:
MANUFACTURER ry-IN t IQUIIJ APALI TY PUMP MOi" WARNING LABEL LOCKING COVER
PROVIDED PROVIDEDES ❑NO Y E s ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PH(7PFRTY WELL BUILDw(, I VENT TO FRESH
(DIFFERENCE BETWEEN _ FEET FROM LINE AIR INLET
PUMP ON AND OFF) ❑YES LNO NEAREST 10
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing I AME TEI+ IMATI RIAI 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 SPA(.(VIA OVER - IvSI')I DIA =P,TS LIQUID
BED/TRENCH RFVt:Hts iATEHIA; PIT DEPTH
DIMENSIONS /,to
r
GRAVEL OEPTH FILLDEPTH DISTR PIPf UISTH PIPE DISTR. PIPE MATERIAL NO 'DISIH NUMBER OF PHOPERTV WELL BUILDING VENT TO FRESH
BE L"V, PIPFS ABOVE COVER EL FV INLET ELEV ISO P FEET
IPES LINE AIR INLET.
o FROM
s ' i3 NEAREST SJ 7 ~c 7{c
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 P1 HMANF NT MAHKF RS OBSFRVATION wEI _S
_ ❑YES ❑NO _DYES ❑NO
DEPTH OVER TRENCH BED J DEPTH OVFH THENCH HFD IIFP TLI OF TOPSOIL SOOUFD SFE T11 11 MULCHED
CENTER EDGES
YES, El NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM: _
WIDTH LENGTH NO. OF LATERAL SPACING [GHAVE L DEPTH BF L Ob% FIVE FIL L DEPTH ABOVE COVER
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR PIPE MANIFOLDMATERIAL NQ i7IS7H DISTR PIPE DISTRIBUTIONPIPF MATERIAL&MARKING
El EV. ELEV. DIA ELEV. PIPES DIA.
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING, DRILLEDCORRFC T L Y CovFRMATEHIAL VFRTICAL LIFT CORRESPONDS TO APPROVED
LAIIS
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERS. Te SERVATION WELLS NUMBER OF PROPERTY WELL. BUILDING.
FEET FROM LINE
S ❑YES ❑ND ❑YES ❑NO NEAREST-
~I -
2 II,~~7
Sketchtystem on Retain in county file for audit. Z-/
Reverse Side. _
IS113NATIIRE TITLE
DILHR SBD 6710 (R. 01/82) `
w `ons/" APPLICATION FOR SANITARY PERMIT
-
lll~~Jll YYY (PLB 67) l COUNTY nEnT oc UNIFORM SANITARY PERMIT #
~~~•oc.RRRTT
3 r~~ InEklSTRVLRBOR G HUM"R RELRTIOnS~
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 81/2x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER
MAILING ADDRESS
r- ti - ..l ~I il~ G L c. : ILK ~ ~ l 1 c I
PROPERTY LOCATION CITY:
1/4 1/4, S ~ , T. N, R • a E (Dr W' VILLAGE:
`rOwN or:.
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
{
TYPE OF BUILDING OR USE SERVED / byo _ ` Q
LJ~J 1 or 2 Family Number of Bedrooms: ` ❑ Public (Specify): r H
THIS PERMIT IS FOR 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.
❑ Seepage Bed E 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 /i'r.'
❑ 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 r
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 ABSORPTION AREA WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
y~ i'c c 1=t tote r_ ❑ 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/MfLRSVI-RI6.: Phone Number:
Z4 L
Plumber's Address: / Name of Designer:
COUNTY/DEPARTMENT USE ONLY
Signatu a of Issuing Agent: fee: Date: ❑ Disapproved
~n L ~'I / S ❑ 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
{
APPT,LCAT'-ON 1011 SANY`AI:Y 131,,I:MIT
S c - T00
This application form is to be copip11'ted iii fuIl 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
}louse"), 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 or Property
Location of Property,52-7- ?.4, Section 31 T /N - R W
Township
Ma i_':- i rig Address V4d
Subdivision Name
Lot Number
Previous Owner of Property S t yZ? .t `
Total Size of Parcel
Ci
Z
Date Parcel was Created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes/ No
Volume c,`,*% and Page. Number 0 as recorded with the Register of Deeds
INCLTinT WTTia TTITS APT11,ICATTON ONE OF TI IF. FOLLOWING:
I. 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
I (We) eeAtc )y that aXe Statements on ,this ~onm ane._ finue, to the beet oo my (owe)
knowledge; that I (we) am (aAe) the. owneA W o ~j the pnope.n ty de,,m bed .%n -th.i5
in~onmation ~ortm, by virtue. o~ a wanAantU deed uconded in the 0{Ogee o() ,the_
County RepiAteh o4 Dee.dA " Doeume.nt No. --7 t' ' , ; and that I (we)
plee,5mtl-y own ,the. pAopopse.d bite. ion the dewaoe ~y.~te_m (ort I (we) have
obtained an eah emen t, to nun with ,the above d,m cA%bed pnopeh ty, ion the
cony tAuc t%on oK said d yA tem, and the name has been day he.conde.d in the- O{¢ice
oK the County Reg.6te,,r o{ Decals, m Dvcumevit No.
IGNAT E. OF OWNER S I_GNA` URF, OF CO-OWNER (IF APPLICABLE)
%r !'T ST CNI?l) DATE S~TGNI?D
H
. H
y
ST C- 105 r
r
a
I
SEPTIC TANK MAINTENANCE AGREEMENT H
St. Croix County z
d
T y
t c (
OWNER/BUYER
ROUTE/BOX NUMBER r-` j _A7 Fire Number
CITY/STATE
~c
zip
~,i
PROPERTY LOCATION: - J
G✓ 4, Section j T ~N, R ` W,
Town of 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
E
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- 10
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
/I
DATE '//✓~v..~~ ~~:5/~
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.
p N
r m
CD CD
= ro W 0
44 C =r
Go 3 TO: o
~ol 3az ~w a m m o '
C: C,
CD cD~E;
0 o0 In m
S m g w o m maw ~
0w'0 (D
7 (D w n. (CD ~ D
co -s-►CD 0
oC=D moo
o m C no (p W
A m a
o ~ o
a
o :o
w= N
w O = C- >
3-c oc3oao
w cn
w ~ ~
N 1 ~ w
O p a (~D O
O
C D'
(D p~ (COO -a -o",
Q
Q O
C CA:
(D N p D C (p
CA o
~omao~
~w C
C w`C'w :aQ O
Q~CL oNm moo (t) T) Z N
C, N
cD D
~.y..
N U) ° Z
7
CD CD =r w (D
U)0 3c~D~cDa
o CD
CD o
~ c ~a =r --'?ocu=ri° S
I Er
Q CA CD
a CD O=r d co V)
ui w a n:E CD c R1
3 co o v (Al 0)
°NIC C C aw N w C7
a co con (D S
= c c0 D
N 0 c f0 mo N N
O CD F;
S=D) g U) a E 0.w aw o
0-
m= mcn
w? w a a a a
ap CCD Q= =r FA,
c§0 NM.~ ~cnc~D~3 m o
W O M to 7 vi n CD O
(D 0 o = oco a c ~m c . ID
c w m
Q
a O S
o a =r c (D w o o V
pa a~3 o o°3
am ~o v3
o o
~ O
DUST Y,, REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY,, DIVISION
LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN RELATIONS MADISON, WI 53707
(H63.09(1) & Chapter 145.045)
LOCA: ION: SECTION: TOWNSHIP/fA"?ttG#.RANffY: LOT NO.: BLK. NO.: SUBDIVISION NAME:
s~-Uw1/ 1/ -3 /T N/R E (or►.
COUNTY: OWTNER'S/B+S NAME: MCAILING ADDRESS:
USE - ~ }
DATES OBSERVATIONS MADE
Iqq__ NO, BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
4-^-~J-s es i de n ce
3 }v, New ❑Replace S _ - ~ 3
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-tn!l D-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:(optional)
OS ❑U ®S ❑U ❑U CJS ®U RU
s`x rug`
If Percolation Tests are NOT required DESIGN RATE:
If any portion of the tested area is in the p
under s.1163.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-1 CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH M ELEVATION OBSERVED EST, HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B \.o' n ai 1 ; \.S' n.S1
4' . ~ Z_ g Lin 1 S w,,'~1t, ~n g \ OA~v~ S
B- Z -~7' 96.3' 7 -7 y C?. ~k 6Y si 7S i 2.0~ h 5i~ i 3-3 Z3 Jt 5
B- 4 C" 8 ; o.-? It .d' fan 5
Z. S' n S W/ A FE- S Pr,`r,S or B,,,
B- 5 ` ~fiv , o. zJ' Ok G~+ S I TS 1 • ? ' Ls'n 5 t i i 41.O JS "v/r_-e1
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P- ) Y 1J O 30 / 7/c~ 1 /3~jb ) -7 l
P- 3 zi TJ® 3 3l j/ YO
P-
P )ti S:ln _Ti
Pz LL. s~.S'
P _
P a is.) ,
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-
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. IIJI T3 R ZEr _f., .fir r~ r ~h\(= S~ CJ Sa~TT I 1,
ss-Z -
SYSTEM ELEVATION
LU 4oo c
h
S, E z _ 104.%- 010 -~--`d
OF w41eD
I o~~
!y -•E
1 17 .w r f
f
'
84/
1
i
Orr
rP -
4
4 2
?.~.Fn~~a e I,I ~S S s
17
I
>'I 14C) C5 F.-N" ►"x woad satz~ i
Z "
3
4 ~-16 6 8 a-
C'TTI h ° ~
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 (print): TESTS WERE COMPLETED ON:
k.Aj
ADDRESS:
CERTIFICATION NUMBER: PHONE NUMBER (optional):
CST SIGNATURE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
I FFA
e a,
<Ar; , 2.1 i'ber pct t")c rye.. 4 s) C9if !''ac€, x..
AB ,
l as yt.z ,4? ! t;,, .E `D C,N `O L t.Cll;~c~ IT! ~~=S
CJescriptjor?s nd co4'31p
i~ C IE LJ: .c i r£CCUraV3!v lcAcatio, your test locC ,tir L. D I t0 SG3
_ A
,r`taV; l ~l-t`?'4P_n..._ nir~G aie clc3 _ho-o"'L, and ~vu
`t
dll-, , I"av r ,s, ,:4rk ,-,o,,I plai,= ...r a, , -,rcoiaOan #£3tii i'~E"'r1 2_
M ,d vL. M, f
.
t., r ..:;.1 r ? .;.::liteI,s a'3U Voi,,i1 L
„
SS S
x _ -x -
N .
n; r
,
e t
cl- Clay
r i11 3 7;4 .E3,L
t Y ,
d, ir,
I 1-n
Y 2r
?.i4 ;r, ~£'ts= F 5l r ~iF~ ,n, r _.ti xr'.~ btia [ i £`si ?.1 , .9Ytf~rsT tr Y r£S`41 ..a
t?i(;?ES'£>
~~~'1Fw ' Crl P
/WIP
X~,
S 'l/f.~ Taw".
.
u~ ASK
qr,
NZ -r4
i
~qy t
4t
I
7o u,) ae 1) rF
i t 1 r. +t~c"R /Pxe P r
( 4 11 ~J
J
r
v
i ! bcs 1
mill
rt [ Nx.k) Ts
f ge " ~aac~ G +1 I
i Bc x a P-,A/
w~~L
"If You Like Our Service, Tell Your Friends"
BIRCHWOOD PLUMBING AND HEATING ,
E. F. GROVE, OWNER `
PHONE 425-5824 ROUTE THREE
RIVER FALLS, WISCONSIN 54022