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HomeMy WebLinkAbout030-2071-50-000 G N a) :E O - d C co~ C (D n A "*41 3 o m 0 0 ° r- 9) w m o • \ D o' 3 o c m o m o co n?i ~ c z E N N N O CD CD C, -,J n p S S 0) r.j O n Q O (D CD cn O O ~O1 . cn 3 o o 7 N ` j O C C O f~ Cn ro b a co D a N O R J CD ~p N Cn a TJ CD C 7C C n C O O N p o (o b ;2r m 3 Z3 N) C) rzr w ~ N • ` z cD CD n r cn o L+ o w w o c err Z c?+ z O O O mo Z ON's T1 p fn N N< O N D 7C co 3 3 - - cut _ v v q O O !V (A ,~~A. O O C I l' f z R O O E _ z ~ z t~ D o o O n o m P+i . CD C/) c c v (Cl CD CD S [ C O w n N E Q 3 7 C~ co)", z (D z • --j o c o A Z 9~ CL C) F! S r a V TJ o o CD v * o O co w 3 z °o cn oN 3 m N z CD w ~ D n n ~ o - I ~ ~ I z a o (D cn I A. A t N W I N O O a A p b N k-j ~ 0 ~ a O o b O i ti s Parcel 030-2071-50-000 03/23/2006 04:58 PM PAGE 1 OF 1 Alt. Parcel 36.30.20.619D 030 - TOWN OF SAINT JOSEPH 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 SHEENA PARKER O - PARKER, SHEENA 1240 HWY 35 HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 1240 HWY 35 SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 3.540 Plat: N/A-NOT AVAILABLE SEC 36 T30N R20W NW SW LOT 2 CSM 4/1117 Block/Condo Bldg: Tract(s): (Sec-Twn-Rng 401/4 1601/4) 36-30N-20W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 924/511 2005 SUMMARY Bill Fair Market Value: Assessed with: 84709 232,100 Valuations: Last Changed: 07/09/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.540 82,100 129,000 211,100 NO Totals for 2005: General Property 3.540 82,100 129,000 211,100 Woodland 0.000 0 0 Totals for 2004: General Property 3.540 82,100 129,000 211,100 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 128 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 it I I T T V COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 ~tj 715-962-3121 800 - 962 - 5227 c CROIX LUUNI'1 itiCi lilt uHTEa 9i`15 .OURTHOM DATE RECEIVED* 9/17 iI+SON, WI 54016 L&Sheena wNER; )CATION: 1240 Hwy 35, Hudson +.JLLECTOR: M. Jenkins INTERPRETATION: Bacteriologically SAFE f41TRATE-N: 2 ppm Above 10 ppm exceeds the recommended Public Drinking Water Standard. Co'tiform Bacteria/100 ml Nitrate-Nitrogen, mg/L i I LAB TECHNICIAN. Pam Gane r 1 WI Approved Lab No. 19 0 l ti OF.\NDEDENpFHr lvry~ C7 "i..C~ =a Means "LESS TiAN Ietec+able Level Approved by.' £ Z PROFESSIONAL LABORATORY SERVICES SINCE 1952 ST. CROIX COUNTY ZONING OFFICE 911 4th Street Hudson, WI 54016 Telephone - (715)386-4680 The St. Croix Co. Zoning Office offers the service of septic and water inspection to Lending Institution, Realty Firms, and private individuals. COMPLETION OF THIS FORM IS ESSENTIAL SO THAT THE PROPERTY CAN BE LOCATED. Please provide the following information, enclose appropriate fee made payable to ST. CROIX CO. ZONING, and mail, along with form to the above address. Testing will be done as soon as possible after fee and form are received. rr WATER TESTING FEE:$ 25.00 (For nitrates and coliform bacteria) WATER TESTING FEE:$175.00 (VOC'S) SEPTIC.SYSTEM INSPECTION FEE:$ 25.00 PROPERTY OWNERS NAME: x 1 i PROPERTY OWNERS ADDRESS:`°;.,, CITY: Legal Description 1/4, 1/4, Sec. , T N-R W, Town of Lot No. Subdivision FIRE NO. ' LOCK BOX NO. Color of house Realty sign? Firm: PLEASE INCLUDE, IF AT ALL POSSIBLE, A MAP, i.e., COPY OF PLAT BOOK, WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET. Testing of residential water requires a sample that is fresh. If the home is vacant, and has been so for some time, the water line must be purged by running the water for several hours before the test can be conducted. WINTER TESTING: Many times water lines are turned off, or sill cocks are turned off, making access to the home necessary. If this is the case, please make proper arrangements with this office to ensure time when entry may be gained. Firm or individual requesting services: Telephone No. REPORT TO BE SENT TO: CLOSING DATE: Signature: Fo rm - S T C- V14 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SEC. T i N-k', ADDRESS jr: iL ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM L Y /y I r 7 I I J~ x lee) t INDICATE NORTH ARROW - 5; BENCHMARK: Describe the vertical reference point used - " c>.i,'Niz=1, , T& Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer: Liquid Capacity: Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Cr_' J.,15 Tank Outlet Elevation: r° Number of feet from nearest Road: Front,0 Side, Rear, O feet ` t0 From nearest property line Front,0Side, r. Rear, ,rte feet Number of feet from: well t -f-- building: (include this information of the above plot plan)( 22 reference dimensions to septic tank) SET: IiEVRRSE SIDI? 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: Pont, O Side, O Rear, 0 Ft. Number of feet from well: Number of feet from building: Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: Length: Number of Lines: 3 Area Built: Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, Rear, O Ft Number of feet from well: Y U/ Number of feet from building: X (Include distances on plot plan). SE1: PIT Size: Number of pits: Diameter: ~C Liquid depth Bottom of seepage pit elevation: Area Built: Has either a drop box O or distrib 'on box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity. Number of rings used: Ei-6vation of bottom of,,tank: Elevation of inlet: Number rtof feet from nearest property line: Front, O Side, C ar, 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: 32 'j 3/84:mj DEPA,RTMENT'OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 CJCONVENTIONAL ❑ALTERNATIVE State Plan l.D Number E] Holding Tank L] In-Ground Pressure ❑ Mound (If assigned) NAME OF PERMIT HOLDER. JADDRESS OF PERMIT HOLDER. INSPECTION DATE. James Pall 214 N. Owen St., Stit&aten, MN BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. FEE. PT. ELEV. CST RrE F. PT ~E LEY. NFU SWJ- Section 36, Lot#2, T30N-R20W,- Town of St. Joseph N-e of Plumber. MP/MPRSW N. County Sanitary Permit Number. Dan Schm%t 3205 S Cnai x 49502 SEPTIC TANK/HOLDING TANK: MANUFACTURER LIQUID CAPACITY. TANK T ELEV.. TANK OUTLET ELEV. WARNING LABEL LOCKING COVER PROV ED'. PROVIDED'. ID~YES ❑NO ❑YES ❑NO BEDDING: VENT DIA.. VENT MATL. HIGH WATER NUMBER OF ROAD PROPERTY WELL BUILDING. VENT TO FRESH ALARM FEET FROM LINE AIR INLET. ❑YES ❑NO ❑YES ❑NO ]NEAREST l~ / ZZ ~',J DOSING CHAMBER: MANUFACTURER. BEDDING. LIQUID CAPACITY PUMP MODEL IPUMP'SIPHON MANUFACTl.1REH NIN LABEL LOCKING COVER "AV .1 PROVIDED. ❑YES ❑NO Y S ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBS FR RTV AELL BUILDING. VENT TO FRESH (DIFFERENCE BETWEEN FEET F LI I AIR INLET PUMP ON AND OFF) ❑YES ❑NO NEAR SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing I TO (ITy / AMETEK ATERIAL 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 _,4[ CONVENTIONAL SYSTEM: BED/TRENCH WIDTH: LENGTH NO. OF DISTR. PIPE SPACING cOVEH INSIDE DIA -PITS LIQUID .rt I TRENCHES f fvttCf'Fi7'IA L'. PIT DEPTH. DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPF DISTR. PIPE DISTR. PIPE MATERIAL. NO. D NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH BELOW PIPES ABOVE COVER E} EV. INLET ELEV. ENS5D PIPES. LINE 7 AIR INLET. I J~ NEAREST so 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- ❑YES ❑NO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TEXTURE PERMANENT MARKER OBSER ATIO WELLS ❑YES ❑NO fiY S ❑NO DEPTH OVER TRENCH BED DEPTH OVER TRENCH BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER EDGES ❑YES ❑N YES O ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW 7 FILL DEPTH OVE COVER. BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE JMANIFOLD MATERIAL . 114,S O DISTR. DIS R. PI E D I S rRIBUTI N PIPE MATERIAL & MARKING E LE V.. ELE V.. DIA. ELEV. DIA: ELEVATION AND DISTRIBU710N INFORMATION IOLESIZE HOLESPACING DRILLED CORRECTLY COVER MAT L VERTIC LIFT CO RRESPONDS TO APPROVED PLANS ❑YES ❑NO ❑YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPS RTV WELL. BUI LDING. FEET FROM LINE - ❑ YES ❑ NO ❑ YES ❑ NO NEAREST Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE. TITLE. DILHR SBD 6710 (R. 01/82) - wT-onsin APPLICATION FOR SANITARY PERMIT COUNTY ~ DILHR - OEPRRTTEnTOF (PLB 67) UNIFORM SANITARY PERMIT # InouSTRV, LABOR 6 HUMRn RELRTIOnS -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 I PROPERTY OWNER MAILING ADDRESS / 1 C/~ / Y PRO ERTY LOCATIO C TY: V GE: )1/4~)1/4, S,'~. , T' ; N, R'~~' E (or) OWN o 'T 7`~ LOT N MBER JBLOCK NUMBER SUBDIVISION NAME ST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER 14 TYPE OF BUILDING OR USE SERVED 61jo I `7/ --~'d(J X 1 or 2 Family Number of Bedrooms: Public (Specify): A14 THIS PERMIT IS FOR A: X 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 Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity f' A'Al &A &A Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total # Prefab. Site Steel Fiberglass Plastic Gallons ks 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): e_. ~ V , Private ❑ Joint ❑ Public 43 - I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signatu M PR W No.Phone Number: i _ ( 7%sr -Y -C-E~ Plumber's Address: Name of Designer: COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: Disapproved , / C'ti ❑ Owner Given Initial 46 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. H V] y S T C - 105 r y ti SEPTIC TANK MAINTENANCE AGREEMENT 0 St. Croix County 0 y OWNER/BUYER ,#NjL~ (tel. L-~IL ROUTE/BOX NUMBER Fire Number CITY/STATE lTL!0SC''N I LIP PROPERTY LOCATION: Section 36 Tt' N, R__;c' 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 pmLer. 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. yo E 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- 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. 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. 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. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - /l Owner of Property f}~ L J l j~/,l Location of Property Section T -7 1-'3 N - R W Township j ~C• Mailing Address Subdivision Name Lot Number b Previous Owner of Property Total Size of Parcel, 5/r~ S Date Parcel was Created Are all corners and lot lines identifiable? _ Yes No Is this property being developed for resale (spec house) ? Yes K No Volumes and Page Number -:i~ as recorded with the Register of Deeds 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) ee4ti6y that aU statements on this ~onm alz.e tAue to the best o6 my (ouA) knowkedge; that I (we) am (arse) the owners (s) o~ the property d"cAibed in this ,.n6orma.tion Aorm, by viAtue ob a waAAanty deed Aecorded in the 066 ice o6 the County RegisteA o6 Deeds as Document No. * 3S.2J >_51 ; and that I (we) pne,sentty own the proposed site 6or the sewage posa2 system (ore I (we) have obtained an easement, to nun with the above desn bed propetty, 6or the const)Luction o6 said system, and the same has been duty recorded in the 066i,ce o6 the County Reg.isteA oA Deeds, as Document No. 2`u- " ! r~Gt"~ IGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED DUS`fMEI~T`OF REPORT ON SOIL BORINGS AND SAFETY&BUILDINGS INDUSTRY, DIVISION -LABOR AND PERCOLATION TESTS (115) MADISP.O. BOX ON WI 539069 HUMAN RELATIONS (H63.09(1) & Chapter 145.045) rsi " I &V y ~?I ttcr.J~ iV S~ZA1 A , CEN- LOCATION- SECTION: TOWNSHIP/4%4H+e+R#,-L-ffY: LOT NO.:BLK. NO.: SUBDIVISION NAME: COUNTY: OWNER'S/ME: MAIL NG ADD ESS: C- s1l d 1 aK C Fi'Y r ~,?t p USE DATES OBSERVATION MADE NO. BEDRMS.: COMMERCIAL ESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: I ew ❑Replace ~4 7 0 ff RATING: S= Site suitable for system U= Site unsuitable for system p., q1 Al tg, to rxs ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN- IL OLDING TANK: REC MM ENDED SYSTEM :(optional) ❑U QS ❑u S ❑U ❑S LRU ❑S ~I If Percolation Tests are NOT required DESIGN RATE If any portion of the tested area is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: P FI E DESCRIPTIONS BORING TOTALO DEPTH TO GROUNDWATER4:*aG4E-& CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTHPMT ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) ) •7 C el 5. B- PERCOLATION TESTS TEST DEPTHi WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER AFTER SWELLING INTERVAL-MIN. PERIOD t PERT D 2 PERIOD 3 PER INCH P- . 7' a 3 3 P- P- P- "U4, /Y777 PLOT PLAN: Show locations of percolation tests, soil borings an h~e dime~ of, t ble l areas. Indicate scale or distances. Describe what are the hori zontal and vertical elevation reference points and show their locat oP;'pn thaLpYr~an.ow surface elevation at all borings and the direction and percent of land slope, SYST ELEVATION /00.0 C•-~ /0917 r f g 3: /j, r/4". ~r y Co 0 At top o ....e, . lot 4ae'. . 'F Y. 16 0. 0 P;3 I m i jet; ref / 4e- t H oo tk- /e c, ,~Zrr ,cwt ~p. o, 4-wa_') s"_ 4 kv+ w dot i s ©AZL-Peso ,r 'fii ~ul' l~stc~ W~Or`fbv~i/~f~ I, the undersigned, hereby certify that the soil tests reported on this form were made by me in acco'Fd ~ h Yhe'proced.4res 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: ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): / 1 3 / CS T RE: i r DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) -OVER - 1 e Avi. 0 c.r c 0 40 ~ :l of u m tin "s n ymw U"M _ 0wh,a,' `mn I The use . . liar y whalc cd ! V . a resA nc, oc carnmemb =s s;wt, MAr,,'t`,1YA . r ?s', of bu &onNis c ..CAB"'";;t od t i.€;anned; it tii~siii~~!~ Mom y y ow a v , va gin, ,fnen point . 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