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Form - S T C - 104
AS BUILT SANI'T'ARY SYSTEM REPORT
OWNER ! TOWNSIIIP SEC. T N-R~y W
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT C' LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H 63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
1
7
Gfi4 Re.~ '
I .,7y~,. 3
srT
Jew cis.
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: Mo- 0r? Proposed slope at site:
SEPTIC TANK: Manufacturer:. G 2-A- Liquid Capacity:
Number of rings used: V' Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front,O Side, Rear, 0feet
^rom nearest property line Front,0Side, (9 Rear,0 feet
Number of feet from: well building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
•
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 fc,~L loom near.,,, line: Front ~c;
de, ORear,
Ft.
0
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: / U( Length: `yi Number of Lines: C
- - Area Built:
J cry
.i
Fill depth to top of pipe: `l/
Number of feet from nearest property line: Front, O Side, Rear, -"I Ft.
Number of feet from well:
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 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 Panufacturer:
Inspector:
Dated:
Plumber on job:
1&~4ZY -Y
License Number:
3/84:m~
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
BUREAU OF PLUMBING
P.O. BOX 7969
MADISON, WI 53707
C an I,u
CONVENTIONAL ❑ALTERNATIVE IlstfatasssiPl o.N tuber
9ne dl
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
s 04
ADDRESS OF PERMIT HOLDER: INSPECTION ATE
NAME OF PERMIT HOLDER.
Barbara Star c/o Zappa Bros. Excavating, N.Hudson
R61-
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN.
SW SW, Sec.29,T29N-R19W,Lot#6, Country Hills, Town of Hudson
Narne of Plumber. MP/MPRSW No. Co. my Sanitary Permit Number'.
Gary Zappa 3300 St. Croix 49503
SEPTIC TANK/HOLDING TANK:
MANUFACTURER LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV_ F O NII ED-ABEL p.O.C'K D O
'Y • YES ONO ❑ NO
PR OP ERTV W L BUILD( NG NT TO FRESH
BEDDINGVENT DIA.VENT MTLHIGH WATER NUMBER OF ROAD: LINIAVIER INLET.
ALARM' FEET FROM
DYES O OYES ONO NEAREST
DOSING CHA BER:
PUMP/SIPHON MANUFACTURER WA , NG LABEL LOCKING COVER
MANUFACTURER. JBIDDING: LIQUID CAPACITY PUMP MODEL PROV DED'. PROVIDED'.
OYES ONO p r f Y.ES ONO EYES ONO
RESH
PUMPAND CONTROLS OPERATIONAL. NUMBEr y F PROPERT WELL BUILDING IAER INLET
GALLONS PER CYCLE: LINE
(DIFFERENCE BETWEEN FEET FRO PUMP ON AND OFF) DYES ONO NEAREST
-
LEN(;TII r DIAMFTEi~ MATERIAL AND MARKING
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowinT9F ORCEor excavation. (If soil can be rolled into a wire, construction shall cease untAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM: uoulo
:
BED/TRENCH WIDTH: LENGTHl NO OF DISTR PIPE SPACING JER INSIDE DIA #PITS DEPTH
~l TRENC RES If ERIA. L: PIT ._....._,__.___~.r.~
L
DIMENSIONS
NUMBER OF PROPERTY WELL BUILDING: VENT TIOF FRESHI
GRAVEL DEPTH FILL DEPTH DISTH. PIPE DISTR PIPE DISTR. PIPE MATERIAL. NOE STR LINE/// y AIR
BELOW PIPES ABOVE COVER ELEV. INLET ELEV EN - ~y FEET FROM
G S c, C L P NEAREST {1 „J
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
DYES ONO
PERMAN
SOIL COVER TexruRE ENT MARKERS. OBSERVATION WELLS
DYES ONO DYES ONO
SEEDED JMULCHED
DEPTH OVER TRENCH.'BED DEPTH OVER TRENCHBED DEPTH OF TOPSOIL SODDED
CENTER EDGES DYES ONO
DYES ONO OYES ONO
PRESSURIZED DISTRIBUTION SYSTEM: FILL DEPTH ABOVE COVER
WIDTH LENGTH. NO. OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: POEDISTR DDISATR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEV. ELEV.'. DIA. ELEV.'.
ELEVATION AND
DISTRIBUI ION COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
INFORMATION HOLE slzE HOLE SPACING DRILLED coRRECr v PLANS
DYES ONO DYES NO
NUMBER OF PROPERTY IWILL. BUILDING'.
COMMENTS: PERMANENT MARKERS: =DYES N WELLS. LINE'.
FEET FROM
~u DYES ONO ONO NEAREST
Toy
c.~~ ~ C~ x.11 C. 5
Sketch System on Retain I county file for audit.
f/
Reverse Side. SIGNATURE _ TITLE.
DILHR SBD 6710 (R. 01/82)
~ Wisconsin APPLICATION FOR SANITARY PERMIT
DILHR r COUNTY
(PLB 67)
- OUSW,gy.LA OF 90R 6 HUTRn RELRTIOnS
InOUST,RV, LA UNIFORM SANITARY PERMIT #
7
-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
_41)1 f
PROPERTY LOCATION
Sl~ 1/4S4)1/4, S't N, R / E (or) TOWN OF: 1`' vL,lON
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME [T-RES-TROAD, ~€cK-EOR-L-Afdt3hhA STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED Z ocz- ll a1 O®~
i~ 1 or 2 Family Number of Bedrooms. ❑ Public (Specify): of
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 ❑ 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
Gallons Tanks Concrete Constructed Steel Fiberglass Plastic
Septic Tank Capacity /~~J f X
Lift Pump Tank/Siphon Chamber /t/1+
Holding Tank capacity
Manufacturer: LtJ6E,E~s C4~c.e f e lVeW :4p,tJGJ y~(U - CL S d ~E/S~ (OUC~Q f 2 - .
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):
,,3 /1(0 /Z ' 3l ' 7L/- 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: *W/MPRSW No. Phone Number:
Plumber's Address:_ 7 Name of Designer:
y~~y 35 NO aw)s0 %v/ r ~ n
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date:
❑ Disapproved
V Approved Owner Given Initial
(cJ 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 639&
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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Owz1E_r of Property
Location of Property Section , T N - R W
Township
Mailing Address
Subdivision Name
Lot Number
Previous Owner of Property
Total Size of'Parcel
Date Parcel was Created
Are all corners and lot lines identifiable? Yes No
fs this property being developed for resale (spec house) ? Yes
Volume and Page Number as recorded with the Register of De k,',
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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPERTY OWNER CERTIFICATION
I (We) eeAti6y that aU, statements on this {foam ah_e cue to the best o6 my (owc)
hnowkedge; that I (we) am (ane) the owneh (s) o{f the pnopeAty d"cAi.bed in this
tinbonmat on {form, by viAtue ob a wa" anty deed neeonded in the 066.tce ob .the.
County Regi~steT o4 Deeds ass Document No. -2-- ; and that I (we)
ph.aentfy own the proposed site. bon the sewage psy /system (oh I (we) have
obtained an easement, to n.un with the above de/scA bed pnopWy, bon the
co"tnuction o{f said system, and the same has been du,ey neeonded in the 066ice
o4 the County Regi6ten o{ Deeds, ai5 Document No. ) .
SIGNATURE OF OWNED SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED -_ll--~
N
a>
ST C- 105 r
y
y
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
d
9
a H
OWNER/BUYER m
ROUTE/BOX NUMBER Fire Number
CI'T'Y/STATE l.lP
PROPERTY LOCATIONSection T N,
Town of St. Croizc County,
Subdivision Lot number
I
Improper use dnd 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 p mper. 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 Cn
to maintain the private sewage disposal system in accordance with x
the standards set forth, herein, as set by the Wisconsin Depart-
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.
tEC-_
S I G N E D
D A T E l' l _/.r- Z/
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.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, , C DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 7969
.HUMAN RELATIONS,
N, WI 53707
(H63.09(1) & Chapter 145.045)
LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME:
s w '/a '/a Z 9 /T Z9N/R / E l o W ~/vDso,~l c .S.iy C'o cw7,e~//s
C~O,UNTY: , OWNER'S/BUYER'S NAME: MAILING ADDRESS:
510 '4 /Mas 1/0 Z_ PS
USE DATES OBSERVATIONS MADE
11)6Residence NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS• PERCOLATION TESTS:
2- New ❑ Replace
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MffOU D : INGROUND PRESSURE: SYSFILH7Ed1jS
G TANK: RECOMMENDED SYSTEM:loptional) o s ❑u s ❑u s ❑u El au
F..Pde',s.'H63.09( ecation Tests are NOT required DESIGN RATE I If an ~I
L y portion of the tested area is in the
5)(b),indicate: Floodplain, indicate Floodplain elevation:
~N 171=Ct', L ~r PROFILE DESCRIPTIONS
BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-IN' - CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- > / • S~ ZJF /3.11. 5 d ,u J J ?1' a . d 74V .
B- 2 I r /•3~ 'hfy- > ~J J~' ' //7 ' /3/k• S/ ,s-'I~~ ~a. s 3-f L/• Q,v . 3S
L'f 6~ vE s2 c s
3 ~/S /O3./X10 >113-" •G7'~~ l3v. s~~ ,zs' s' R 7'o,P-/.3,.,.
B'/ . v cs.
B-7 S/ 103.1?~ rN-- S ' •?5 _Dk 3a.S/, •~L',&N. IS, 33 -s.
7,;I v Y es wdz^ P,--,f- ,e,4 ('e_ -
13-5 /l•D ( 106.20 qty -O ' . 33 ' o,(-- dN - T/~ . PS 13,,- /s, T417 ae-~ cs
B-
50ef¢CE /EU~f%iovS df ~~~'CS PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER IN AFTER SWELLIN INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P- l S.CoZ 00.5' 2- 7 eoM - 704' S 10•Ir-14E- 41
P_ Yj7_V1tT--0 IA~ -Ole C- 5".
P- O- 2_ S -
P-
P- 3 7. /oz. v
!.V SS O4- M%A-) TES
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. 0~0~1 /2
l3 ~ ~ ~'x " 7` o-v = ~Ty 3P ter.
SYSTEM ELEVATION A e - fr.
.
.
E
.
3
t -
3
N
E
K 3
This site APPROVED •
for a eQnven#ionateptic system.
. E r
3 ~ _I
•
E . E.
i
I, the undersigned, hereby certify that the soil tests reported on this form were made by mein 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 W RE COMPLETED ON:
TromrS'ITE TESTING CO. 3--1 e y
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
MINNESOTA LICENSE NO. 00663 S f =02 1 3P4--~j
WISCONSINUCTNSE CST SIGNATU E:
R~ 32 0=L RU., IW S0N8 W154016_ -
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
t
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I rs _ lL.t ;,J vvri for 3v tzar .i~.a){lE ct,t,(,E .
UlA K E A LFC;IR 6n r: ,tat :€,t <; { l at 1cacalin a } )r- t-st (ocatior)S. , ; i .
lo- ,
C}oln! are, "'Jea m .,hovvn, and a t' 1)e, iPlai@l
~l ar-,, :I of f to 6 , vP.$t 7~t3(Ptl,a, ne `~:.rr,>h~=1 ':a 01a1 r s€"t
of tF ;ate (S ach as o1, a ,r var, r.l± va, ucf fn's tic., apni . , . ,a€ev i`},A, it VhO tIp, )Ff)Ot iate i
t[-, ?z.r Y3`?and plt,lcr Your aiddYea ~ d gout
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Oil ) X43`° }r3 ,xjt'.
PERCOLATION TESTS IIS
REPORT ON SOIL C3®RINGrS 'I
PLAT 'PLAM PROTECT -U. D. ~'ovUTiAI /~~//s
f:)Arcj,,~~ /X
HOMESITE TESTING Co.
5,4016 X 5 7- 02. Ye2-
~ Pf~ 7~%'~r
PR®P05ED ViNS€ MOST LIE 23 Fr OR MORE FeQ0~6 gLL TEST f3~P~'~S.
PRoPoSED U1Ea mvsr me 50 Fr.
• = L3~C.E'f~ssE p®TS =°i~T®.al Lt~ELL.
pGdS N&-,-) z o 7- 1 ; A.I
77
LEGEND
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30'
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P
€TM - i r
I d E~.~~~ ~ e spa ~ e
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e. 0012 r0st
/N,
CvL-VA- SAS
---A
r 76
M A~7f- /,6 ~
PLC ~7
PLOT and CR O55
-POP J1, (0 7' SmrioN PIANS
4r l33
t o
so
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P -
i , ~ 35 I m
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lucl(
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Fresh Air Inlets And Observation Pipe
SOIL. Tf: T7,0cj 13Y
HOMESITE TES iNG 0o0. ~~pprc?vec•. Vent Cop
HUDSON, Wis. "A016 Minimum 1218 Above T-
Final Grade ~yf~ l,)t:~j w
~ MUD 6 jc'
4" Cast iron
Above Pipe
Vent Pipe
i o Final Grade
Marsh Hay Or Synthetic Covering
~ ) JA ~S
Min. 211 Aggregate
4k) Over Pipe
Distribution - Tee
Pipe 0 0 0 0 0
T°~~ Co 10 Aggregate 0 Perforated Pipe Below
3
~j Beneath
! Pipe
0 Coupling Terminating At
r - °r~ Bottom Of System
i
I~ii$ON CCh1P.TRY CLUB
WEST LINE OF THE SW I/4-...-.-_.
S m N r w m N 00° OO, 11 W 42 9 00 a■/J
'3'626' U CENTERLINE _CAR_MICHAEL_RO
AD
N
of A VJ
z n yO I NOO100'11'W 429.00' Z n
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CARMICHAEL ROAD ,
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