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Form- S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP SEC. T / N-R W
ADDRESS i< 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
I
I I i i
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i
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used „ i
Elevation of vertical reference point: iy Proposed slope at site:
SEPTIC TANK: Manufacturer: Liquid Capacity:
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: L Tank Outlet Elevation:
Number of feet from nearest Road: Fronts, Side,O Rear, 0 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)( -e' ere-)c ".-"mengi er,~ e se r-~ ank)
f
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size T-
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, CSide, 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: 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: j
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:
r_
Dated: - Plumber on job: f / I r"r
License Number:
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969
MADISON; 01 X3707 BUREAU OF PLUMBING
.CONVENTIONAL ❑ALTERNATIVE state Plan LD Number.
(I! asslgnedl
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER. INSPECTION DATE.
Douglas Thompson R. R., Deer Park, WI on & BENCH MARK (Permanent reference pmnt) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.. CST REF. PT. ELEV.
SE NE, Section 11, T31N-R18W, Town of Star Prairie
Name of Plumber MP/MPRSW No. Cou nty. Sanitary Permit Number:
Gary Steel 3254 St. Croix 54980
SEPTIC TANK/HOLDING TANK: ; r
MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
1 T PROVIDED PROVIDED-
l`~' ❑YES LINO ❑YES LINO
BEDDING. FENT DIA.. VENT MATL.. HIGH WATER NUMBER OF ROAD. PROPERTY WELL. 181111-DING. VENT TO FRESH
ALARM
LINE, +v VVV AIR INLET
YES LINO FEET FROM
i ❑YES LINO NEAREST
it.
DOSING CHAMBER:
MANUFACTURER BEDDING. LIQUID CAPACI TV PUMP MODEL PUMP/SIPHON MANUFACTURER WARN ING LABEL LOCKING COVER
PROVIDED: PROVIDED.
❑YES LINO ❑YES LINO ❑YES LINO
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) ❑YES LINO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing wcSL+ 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 COVER INSIDE DIA. .PITS LIQUID
BED/TRENCH ' TRENCHES r MATEfa IA IF
DIMENSIONS C7 ` PIT DEPTH
GRAVEL. DEPTH FILL DEPTH DISTR PIPE DISTR. PIPE DISTR.pppIPE MATERIAL. NO R NUMBER OF PR OPERTV WELL. BUILDING. VENT TO FRESH
BFLOW PIPES "'UV' COVER EL~ INLEr ELEV. END o~/Z PIP . FEET FROM LINE AIR INLET:
7 (~S l lo' NEAREST-~I / ,
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-
❑ YES LINO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
❑YES NO ❑YES LINO
DEPTH OVER TRENCH. BED JDEPTH OVER TRENCH: BEL, DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER EDGES.
❑YES LINO ❑YES LINO ❑YES LINO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. ]LENGTH NO.OF LATERAL SPACING. JGRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES.
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL JNDISTRIBUTION PIPE MATERIAL & MARKING
ELEVELEVDIAELEVPIPELEVATION AND
DISTR IBUI ION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
❑YES LINO ❑YES LINO
COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS: NUMBER OF PROPERTY WELL'. BUILDING.
FEET FROM LINE.
❑YES LINO ❑YES LINO NEAREST
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNA RE TITLE
DILHR SBD 6710 (R. 01/82) 1(
wlsconsln APPLICATION FOR SANITARY PERMIT
(PLB 67) COUNTY
,D' L H R~
oEaRRTmenT Dv UNIFORM SANITARY PERMIT #
M InDUSTRY, LRBOR 6 HUMRn RELRT10nS
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Cade 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
I
PROPERTY LOCATION CITY;
VILLAGE:
7 1
-
1/4 /4,S N, R ,E, (or) W TOWN OF:
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED
1 or 2 Family Number of Bedrooms: ❑ Public (Specify:
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 Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer: ^ '
i /y.,~ < 7/7-7777, - it -
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):
- j Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Pl~mber (Print): Signature: MP/MPRSW No.: Phone Number:
Plumbs s Addre : Name of Designer:
14 J
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date:
❑ Disapproved
f~ r ❑ 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
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.
APP',TCA`! ON F01: SANITARY PERMIT
STC - 100
This app! heat Lon form to he comn'_er e d in ful ? 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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Owner of Property
Location of Property , do 67 Section N - RW
Township i> f._~ .
Mailing Address ~L ~Gf E G()
Subdivision Name
Lot Number
Previous Owner of Property
Total Size of Parcel
Date Parcel was Created u'
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume and Page Number as recorded with the Register of Deeds
INCLUDE WITH THIS APPKTCATTON ONE OF THE. FOLLOWING:
Cl) Warranty Deed
2. Land Contract
3. Other recordings filed with they 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 (A) eenti"l y that att otatemenS on this foam ate tout to the best of my (out)
knowledge; that I (we.) am fate) the owner (b ! of the pnoperr ty deActibed in this
-inf onmation foam, by viatue of a wattanty deed necoaded in the Office of the
County RegiAtet of Deeds a6 Document No. _ - _ , , f, ; and that 1 (we)
p4cAen-tey own the pnopoAvd Aloe {ion the sewage iAp a. system (ore I (we) have
obtained an easement, to nun with the above deAen.bed pnopenty, {ion the
cowsttuction of said Aptem, and the Aame % been duty neeonded .in the OlAice
of the County RegiAten oj'~ Dee.d~, a Dceumerr,t No.
SIGNATURE OF OWNER T SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SAY'r) DATE STGNEU
r
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y
SBPTIC TANK MAINTENANCE AGREEMENT
0
St. Croix County z
d
Y
OWNER/tft rR l u u ~ ~AS /i ,r , _
ROUTE/BOX NUMBER Fire Number
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CITY/STATE ZIP
PROPERTY LOCATION: Secti_onT_, N, R W,
Town of }-t=.fi✓t_~ St. Croix County,
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Subdivision Lot number
I
Improper use Jnd maintenance of your septic system could result in
its premature failure to handle wastes. Proper maintenance con-
silts of pumping out the septic tank every three years or sooner,
if needed, by a -licensed septic t_an_k_ 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, 1-978. St. Croix County
accepted this program in August of 1980, with the requirement that
owners of all ne.w s-ystems 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. Ho
F
I/WF., the undersigned, have read the above requirements and agree CIO
to maintain the private sewage disposal system in accordance with x
the standards set forth, herein, as set by the Wisconsin Depart- w
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
i
St. Croix County Zoning Office
P.O. Box 2'27
Hammond, WI 54015 1
715-796-2239
Sign, date and return to above address.
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DEPARTMENT OF REPORT ON SOIL 'BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR RANQ E - PERCOLATION TESTS (1151 P.O. BOX 7969
HUMAN RELATIONS \ / MADISON, WI 53707
(H63.090) & Chapter 145.045)
LOCATION: SECTION: f TOWNSHIP /N dN+Ca-PAL-a-TY: LOT NO.: BLK. NO.: SUBDIVISION NAME:
CO_U TYY OWNER'SfBFfEkS NAME: 1 MAILING ADDRESS:
IN J USE DATES OBSERVATIONS MADE
NO. B` RMS.: COMMERCIAL DESCRIPTION: ~ (PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence ❑New gReplace
7 -7 7
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:(optional)
~s ou [.s ❑U , V1S ❑U ❑S pU oS ,EU
If Percolation Tests are NOT required DESIGN RATE: I If an
I( y portion of the tested area is in the
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
' j rl PROFILE DESCRIPTIONS ~rrr L ~71 v `
BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER BEPfiH IJV, OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
ap -
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B- I i
~G , )
B-
B-
B-
(iF~/rrrH<i~ PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER k1d1'1~ES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
1 l~lP- Y -
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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.
SYSTEM ELEVATION
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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:
'j%-~ 7-
ADDR_ESS:: CERTIFICATION NUMBER: PHONE NUMBER (optional):
' /
CST SIGNATUR ( -
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
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SrPT IC TANK PER,`? IT NO.
R Z P O R T O N S O I L P Z R C 0 L A T I O N T Z S T
A N D S 0 1 L B O R I N G S
TO
DIYISI"' , OF HEALTH • ",U-MING S;ECTI
P.O.Boz 309, Mad:a- , Wis. 51701
r"'~Y
Purm.v,nt to H 62.20, Wis. 1dreinistrative Code Yir
6
P Z R C O L A T I O N T I S T EA
Tent Daptb Char at.-;r of Soil hours l3r<ter Test Time Drop in Water Level Inches utas
Number Inahas Thic%ness in Inohes Since Hole in Hola Interval Second to Next to Last To Fall
1st Wetted Oven:i<ht in Isinuta Last Perio',Last Period perlod C?zt< Inch
Exampl~I
P - 0 36^ To Soil 1011 Clay 2611 25 I Yea or No 30 1/2 ?12 1/2 60
l A 17 / U 6T
RECORD DATA FRC' INIMUM OF 3 TEST HOLFS
Compute size of absorption area in accord with H 62.20 Wis. Administrative Code.
S O I L B O R I N G S- Minimmr 3611 Below Proposed Aheor~tionsyxte -
Bo in„ fatal Depth Ruth to Grou Ground V41.ar Do h to Br. rock I
Nu , t= Inohos Observo7 FPtirated Oboe"rVed FR4 !mated l~ Character of Soil wi i Thiokn6,,a in Inohas
B 0 7211 72'1 Black Toa Soll 1211 Clav 18,1rc. 2.811, Gravel 2411
-
R?=RD DATA FROM MINIMUM (''r -3 BORE HOC'S
PF OF OCCUPANCY:
RESIDENCE: Number of Bedrooms OMs (Specify) } •,~7~;-, Number of Persons '5
D WASTE GRIND-RI Yes No ;--"'Dishwasher: Yes No l-~Automatio Clothes Washer: Yes No
FFLUEN'T DISPOSAL SYST-"4: Ni:J r. EXTENSION ADDITION ~ REPLACEMENT
Tile Size No.Liri.Feet Trench Width Depth Number of Lines
Seepage Beds Lingth Width Depth Tile Size No. Lines
o~ Seepage Pits If,,,ida Diameter -Liquid Depth a
I, th-• urdersign&-d, hork:*y certify that the pe",,,Iation testa- reported on this form were made by me or under my super-
vision in aooord with do procedures and methoe.. , peoified in Chapter H 62.20 (13), Wiso-nsin AdmJnSntrative Code, and
that the data reoorded and location of test holcs are correct to the best of my knowledge and belief.
NAME if~r t'
: TITLE
(Type or Print
REGISTRATION NO. MASTER PLUMBER LICENSE NO.
ADDRESS 4r- / ,~'(l', r 'J1.
DATE l SIGNATURE
I
X 9310. y~ 230 `1ST `f x 2-.3
Wirconain Depart!,"nt of Haa.lth and Social Services
Plb. X167 3/70 Division of Health •
SEPTIC TANK PEPY1IT APPLICATION ~D 7b-7_Y"6
TYPE or USE BLACK It: 3 A-er
a
A. OWNER BE PPOY*pTy - ' 'e- k, 2-
Name Address (Strest, City, Zip Code)
r ~
IDOU
B. L`'"kTION OF PROPERTY WiTRE SYS ' M WILL BE CONSTRUCTED.,_ ALTERFM OR EXTMED COUNTY
Cht,;k One:
. CITY VILLAGE _ LEGAL DESCRIPTION 60Y
TPW"cc1P i `}yam-'
C. IS LOCAL "=.~MIT RERUT.RED FOR THIS WORK? V11111 YES NO v PERMIT NUMBER
D. SEPTIC Tk,:X CAPACITY Gallons NEW INSTALLATION ty REPLACE4ENT ADDITION
MATERIALS: Prefab Concrete V Poured in Place Steel Other
NUMBER OF TANY.S TO BE 1NSTAL, /
E. TYPE OF OCCUPANCY
Check One: one or Two Family Residence V~ Coar ial Industrial Other
3 Specify
Number of Person° to be Acco=,o3ated Nu -er of Bedrooms
F. APPLI '"::S, F'",'' '-cod Waste Grin. :r YES VNO Automatic Clothms Washer YES ~NO
tzL
ishwasher YES ~NO Automatic Potato Psel6' YFS -1N
v
°ther (Specify)
G. MASTER F'-'X ER BAKING 1 ' :TA('. ' T-,O14
i ~
Nams: Address= l-u Tp . - ~~ic Yd.`- .:5 l oense Number:
Signature of Applicant: MP RSW 14:`;
Address:
H. (To be Compieted by Issuing Agent)
Date of Application Fee Paid ~
Permit Issued (date) Permit Number /
Agent (Fn.%e) Fori
Town, Village, City, County, etc.
(Spec'. l' j
Note: The applioation cannot be considered for filing until all of the above questions arz; answered and the
fee paid. Agents will forward application, the fee of 41.OU for each septic tanK rind the third copy
of the pet^nit (canary) to the Division of Health. Checks and money ordrrs should be made ps""bls to
the Division of Health.
Do not writes a space below - FOR DEPARTMENT USE C,NLY
I. DATE RECEIVED G' J 7 ACC ,YTED BY - Rb"PUR,"lCD
(Initials) (Date) See Coe
FEE: RECEIVED ~ VALID. No. 36 PERMIT NO.
es or NO)
REVIEWED BY APPROVED DATV'
(Initials) y Yes or No
COMPLETE OTHF" SIDE