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HomeMy WebLinkAbout020-1150-30-000 Q C/) Q -0 d = 7 n 0 i 0 (D i >v n 0 O N O O w c C w° "*A• N 3 0) :3 CD d N m CL ~ O O O ~~11111 Z m O _ C O O O m CD _co C N N 8- a O 3 N W O O O CD CD 0 C) 0 _0 5' (D 0 r CD CD O S O r ~ y CD O O O (DD In ~ ~y (D (a O 0 a Z3 W C a C N CD C) N 0 N W (7 C, u N) CD (D Z co co N y 0 C E 3 Q n x m ul _0 'D -0 0 to 3 c~i> ai ai a v I ~ ~ vvva ~ rr n 0 0 CD ID D (D o N• I ~ q d v N rt H fD G7 L? v - n H rt O N O O N N (D U1 U) CL CL C:) cn CD Z £ rt H v O D O_ a G x H n m O N ~+I • t7' r-r (D (a N CD (D f'1 d I Z ci O H t n r'.L_ o o z Z N Z (D SU N I £ rt p w .O. 1 . N ~ a i A GZ~ O ~i I O L n 0. rn o n H z --I w x p N L=J W m w (D (D C G + -o a m rt I t~J m O fl 3 k v y (p A Z Cl) (D (D . 3 a C n n G U) Ci W (D O. O N. \ W O cfl -n _ H % W co o a A tn N c G (n A O Q N ~ a t O (D N n N v a N O A 0 lz ~ A CD V O O yO 6 CD O Q V s"y ad'e b AS BUILT SANITARY SYSTEM REPORT 40 OWNER TOWNSHIP SEC.33T % N-R ~W ADDRESS ST. CROIX COUNTY WISCONSIN. SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of. H63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM z 20 0 r , I di a t N r h r r w T- BENCHMARK: (Permanent reference Point):ADescribe:, Elevation of vertical reference point: SIo1) at 5itc: SEPTIC TANK: Manufacturer: Liquid Capacity: Number of rings on cover Tank manhole cover elevation: /!1•`~ _ Tank Inlet Elevation: Tank Outlet Elevation: PUMP CHAMBER Manufacturer: Number of gallons Number of gal. pump set for a cycle gallons; Total capacity of distribution lines gallon: size of pump head; gallon per minute horsepower ;brand name of pump and model number Type of warning device HOLDING TANK: Manufacturer Number of gallons Elevation of manhole cover ; Type of warning device SEEPAGE PIT SIZE;- Number of pits feet diameter feet liquid depth seepage pit inlet pipe-elevation bottom of seepage pit elevation feet. SEEPAGE BED SIZE: number of lines E width length- the depth SEEPAGE TRENCH: width- _ length PERCOLATION RATE AREA REQUIRED AS B ILT I Tom- _ C DATED PLUMBER oN 3OB LICENSE NUMBER 3 DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR LABOR & HUMAN RELATIONS SAFETY & BUILDINGS P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION MADISON, V':! 53707 BUREAU OF PLUMBING (CONVENTIONAL El ALTERNATIVE F!777 Holding Tank ❑ In-Ground Pressure Mound NAME OF PERMIT OLDER: ADDRESS OF PERMIT HOLDER Lundgren Bros., Inc. INSPEDT NDnr 715 Michaelson St. N., Hudson, WI Z 2.l 31/ BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PL ELE V.. NE-14 SE4, Section 33, T29N-R19W,Lot#25,Countryside Vill.,Twn of Hudson Narne of Plumber. MP/MPRSW No.. Cou my Sanitary Permit Number: Roger R. Evenson 4183 St. Croix 43636 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELE V.. TANK OUTLET ELE V.. WARNING LABEL LOCKING COVER Weeks 1000 100.90 100.59 PROVVIDED: PROO~V77IDED: rl :VENEjL IGH WATER YES ❑NQ LFF~JY& ~fQQ 7 ARM. NUMBER OF ROAD: PROP ERTV WELLBUILDINGVENT TO FR ESH FEET FROM AIR INLETS ENO 4" DYES INNO N EAREST 100+ 100+ N 39 N DOSING CHAMBER: MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL PUMP/S IPHON MANUFACTURER WARNING LABEL JLOCKING COVER DYES ENO PROVIDED: PROVIDED: GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL DYES ENO DYES ENO VENT T IR INL FRESH (DIFFERENCE BETWEEN FEETNUMBER OFROMF PROPERTY wELL BUILDING A ( LINE AR NLET. PUMP ON AND OFF) DYES ENO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing Nc TH DIAMETER MATERIAL AND MARKING, LF1 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: BED/TRENCH WIDTH LENGTH NO. of DISTR PIPE SPACING covER NSIDE EIA =PITS unulD DIMENSIONS 18 37 TRENCHES 6 r nATERIAL: PIT DEPTH GRAVEL DEPTH FILL DEPTH DI$TH PIPF DISTR. PIPE DISTR. PIPE MATERIAL: O. DISar BELOW PIPES ABOVE COVER FLEV INLF 1 ELEV. END. NUMBER OF PR OP ERTV WELL BUILDING: VENT TO FRESH PIPES FEET FROM uNE AIR INLET 6+ 36 95.7 95.34 2729 3 NEAREST- 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 NO meets the criteria for medium sand. TIONS MEASURED. D E SOIL COVER TEXTURE PERMANENT MARKERS. [11 BSERVATION WELLS DEPTH OVER rRENCH.BED DEPTH OVER TRENCH BED - DYES ENO DYES ENO CENTER DEPTH OF TOPSOIL SODDED SEEDED MULCHED EDGES DYES ENO EYES ENO EYES ENO PRESSURIZED DISTRIBUTION SYSTEM: NGTH NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER BED/TRENCH j TRENCHES: DIMENSIONS MP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEVATION AND EV DIA ELev. PIPES DISTRIBUTI ON INFORMATION LE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS. DYES ENO DYES ENO COMMENTS: PERMANENT MARK EH S: OBSERVATION WELLS: PROPERTY WELL: BUILDING. NUMBER OF LINE DYES ENO DYES ENO NEARESOM 3 r~1 5.58 1714 r%c.;l in ~ree M I 105.58 2.3z 3.(,O 9~8 y.99 9.4z 9 S~ 10,3 ~gy'S3 Sketch System on 9 .91 0 9 Reverse Side. County file for audit. S DI LHR SBD6710(R.01/82) M wlsconsln APPLICATION FOR SANITARY PERMIT (;1D1LHR COUNTY (PLB 67) OERRRTTEnT OF UNIFORM SANITARY PERMIT # InOUSTRV, LRSOR 6 HHUTRn RELRTIOns 1,~,.✓ j ~ - Gam' ✓(t 7` Ll.r f i a L.J.v 'T ~ -Attach complete plans in acct&wlth 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 lJ ~ LSD -.11. i`";_ ? t.,,t ~ §~yr ~,'u f ^ 4:. A PROPERTY LOCATION CITY: V j~ C 1/4' 1/4, S 33 , TZ'', N, R ' E (orY W OWN OF:) LOT NUMBER BLOCK NUMBER SUBDIVISION NAME t-REST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER R TYPE OF BUILDING OR USE SERVED LY 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): 1``f THIS PERMIT IS FOR A: Lk 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 L:1 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 w, "y Lift Pump Tank/Siphon Chamber Holding Tank capacity fA Manufacturer: U 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): Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the priv Ke sewage system shown on the attached plans. Name of Plumber (Print): Signatur MP MPRSW No.: Phone Number: Plumber's Address: Name of Designer: COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ' ~ ❑ Disapproved B i L ~ Owner Given Initial r~ ~ 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 1 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. Form - S T C 100 Owner of Property Location of Froperty / ~.7 Section j_ T N R W Township Address Subdivision Name - Lot Number , Previous Owner of Property Total Size of P&r.cel. Date Parcel Was ,r:e;at d ~ Are all coraer.4 Yes-_ No Include with this, a Ali.cation one-of the foilowing: .Certified Sur*,vey Map .Deed .band Contract, or .Other I:egal, Dca=`ument which describes the property PROPERTY OWNER CERTIFICATION ~ (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 or a viarranty deed recorded in the Office of the County Register of Deeds as Lac f° R ,I~ r t No , pl'81~ by own ihs proposed sita b7 tha .sew:1go disposll system (orI (wt, have obtained an oas'aiment, to run with Jij above .sex1,5cribe€# property, for the construction of said system, and thi sarne his hoen duly racorded in the Office of the County Register of Deeds, as Document No. r - z_ r SIGNATURE Of OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE i OATS SIGNED GATE SIGNED Wisconsin Legal Blank Co., Inc. Wis. WB-44 Counter-Offer Approved by the Wisconsin Department of Regulation and Licensing 5-1-82 COUNTER-OFFER _ ,.e~ 7 . . 1 The Offer to Purchase dated • • • • • • and signed b . . . . . . . e~•°J 3 for purchase of real estate at . . . . . . . . . . . . . 4 is countered as follows: ??p...,... . i~~ t.e...~~~e~...a.?. . G . /t~.. ....:...../Ir4r4~r:~...~?• /lj?ZCLl~Z.- /2/..... • . ~/f• t•O . . C,I.LG. . . . fi ...y~ •7 . . . i. ~z.... y: I I e~iFiQir`r' ~ -....mss . 15 16 Seller agrees to sell and convey the above property on the terms and conditions as set forth in said offer and this Counter-Offer and 17 acknowledges receipt of a copy of this agreement. The warranties and representations made in said offer and this Counter-Offer survive the closing of Ip, this transaction. Iy This Counter-Offer must be accepted on or before .i • and it shall not become binding upon Seller until a copy of the 's agent at 20 accepted Counter-Offer is deposited, postage prepaid, in the United States mails, addressed to Seller or Selleor by personal delivery thereof 21 22 to Seller or Seller's agent. r 23 Dated: (Sel 24 Seller)..... 25 20 27 The above Counter-Offer is hereby accepted, (or) 2R 29 . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 32 34 35 Dated: ~c )iD P p uy c (Buyer) i8 311, Buyer's above Counter-Offer is hereby accepted. 40 Dated: . . . . . . . . . . . . . . . . . . . (Seller) 41 42 (Seller) 43 - POINT OF MATCH LINE - SHEET 2 SOUTH LINE OF SE 1/4 MA'-,H LINE -SHEET 2- BEGINNING S89°5fi19"W 131901' V 476 49' 342.5 2 yob" - 336.91 O o • ® ~ c? 388. 589°5B 19`fr -i< 569°5619" W w cn 8:.4.92' f y ' >r W m O A N 24 9' m ~ 1 ~~J m_ Y T N k m Cwz p m N m- / III N S W y D OJ N j 1 ~J_- w f T x .F f _h m All r. c Q A rk z n _ z Cj r b j' pp~ ~U 2 415\ / ' 2 61 36 m c m ~ m - 46ti 9y ti S9°5619'E 451.18' 87 2 rnr©~z n t c N 83 m ~ O 2 b v O -I O ~ ~ %r ~ JI SY9o N `p _ , i fT ~ / N ~ m n n ~c m n N 1 ~ GT mo H o N q-L4 OgN eti - ' ~~3 9, Z \ ~Fme 'L r L Ni =i x m O r c 9 ~p•~; -i- n L L G O wG y~e 6\s2U Lt •GJ b f L O w / 6,6. .gym / 90 ?9 a mom' N > co ry ry 0 y~ W 1919 ~ _ ' 32~ m N j Zd m 20 si -N, m Q ~1 ^ ~ N o? / Iege l 1n N ~ 9 = N N 1~ A S89°44'16 "E 235 86 / v v A ~r N°'m 5pO £ u - O G)~ im SSY° P c m ~a a O O < ~Z 'SS~O / jnJ m v ii _ O Q C ^i J fr T.. 9 m 166 ~ 'F- A m 0, m m tD rn O ~6\6?. v o _ 10 a,♦~,'" 599°44;E 38766 % y ii„•. 3-. - •1 p= - D C1 13V. 96 255 82' m m f w (:1 196°i0 ( 161°_SJ• v b ~ NF~~A N NS-: y°+8 ~ N IN $ G~. lo p ry T- m F U N N= MM m m a v a N N N o o G fm ~ ^W .w w o nN D- ti 2 209°JI' ' N a m ~ 2 N i5a°29' W ~ \ m L ~ ~ ro S89°44 I5'E 409 44' \ z S\ 20 E D X157 589°SSW l 224 20 185.24 s~ Na9°593o'w 1785 K \ \ ~ S~ N ~~~fl° 625 3 w , m0 rsz ° Zv ` `Q ~L2 V il~.e lp S' 0, \ DL 0p0~G12 G v \ N n" N ,t^n \ 3,£Z,IZebBN N Lat e, DCD CII y Sf6bZ A 22° \o - r G O N Ywe a m (1 qA s- 1 i;N ,CG-9 ~JV NP; 46~ 0 e IF \ \yF f iv L N69'44*16"W 39753 \ T \ m E O1 tO 15000' 247 93. ~ 5~ \ ~ n V 589°44'Ifi'E 31384' ~ o I w ~ o y g,9 a m 235 70' 78 14 frl \ \ I G1 N N °iF A p o m G 68 N _ - II -I D N £ O N99°44'16"IN ,I oe os N m yb N_ A- -i y 2 N N. O CDi J N d_ p D I I , 04`Q £ f L N N=S C IV 71 I D w a 3 D Q~ I d o 100 z!n m I ! < N N m v A w fTl N G'S N69'< ; 4,W mllz oN m r N m l L4' 40'(N~^ ~7-- w 2 D m- m to O m N 1 11: O m O ~1 i... tryiZ (,D o N m rn o o N m _ ` N89°4416 W 36595 v 1_ D m W,+~° E m w. Ss'w 5000, • 05. Jim 111v ;i IIC x m. -i n ~r-~ os m n• 2~~ 255 95' - _ ` ~s~ f f rv ! vN `Om Eh 66f 350°98N lof ° / 00002 £7661 m p ti N h:.T 7701 INS ~i 3Nd~ m 91 T -_-~~t~J~~:..~`~1 ~^!1.~ n 1~s~hA9°'13'16 'N 372. 10. 3}~-~ MvA fb b07 M50e985 - _ vJ. J N Si u a~,l0 l i~6 -I DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS I{~IDUSTRY, DIVISION LABOR AID PERCOLATION TESTS (115) MADISON W 7969 HUMAN` RELATIONS (H63.09(1) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP/P_Q LOT NO.:BLK. NO.: BDIVISION NAME: ,4/,r '/456'/ 33 /T,29 N/R19 L"W u zs YSt D. ~/JL COUNTY: OWNER'S/BI_4'T_Cn_5 l!AFMj!: MAILING ADDRESS: 5r. /~3 F J Eye ~e L O I, hk USE DATES OBSERVATIONS MAD PROFILED SCRIPTIONS: PERCOLATION TESTS: NO. BEDRMS.: COMMERCIAL DESCRIPTION: Residence M New ❑Replace RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM:(optional) 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: A Floodplain, cate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- / .O /00.0 6VA1;6- , 4 O. q h r. B- .O 577-3 A10A1,e >8,0 X$ r. B- 3 7.5- ,&•O AIOAI~r 7_4' 0.7 „ 1s ' lv 8 S fir. B-4 7, r ltloAle ;;;,76" o. 5, SA 1S ' 7. Q n AIOA!a ;~-,7. o I. I an 15' S 9 Bn s7 B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P- OA19Z s 7 .2 P- P- P- 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 9iEA4D 33 0 2"IROA1 PIPt rO. Q so/! $arvrtq'f Number v A 0.1' and 10C4*10 n P&itC Tcsr gws0 I ~b ~ Loc►~~~~ 0.Z p•z~p~ 3 - ox~G rte' T N L_~o 4 E 979 X { j~ 1 --30 1, 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): Jf E, s- T SWAA150AI TESTS WERE COMPLETED ON L-~- CERTIFICATI N NUMBER: PHONE NUMBER (optional): ADDRESS: A7,3 A"'Z M s?-, _ _ S 3 S'.3 ST SIGN URE: ~I F ~ , . S~ t-i i z ,.3=,a E~ NO!= ,=1F1stC,# t;. 3 .a t<, ; t;u!} L3 te,'C c_'etl a4r epzA nu7 ti i. u r,r ,,,iC?'7?~ E - shit W M b ASI E E- - OHT NI . _ R A e O u` INC IAN ON4_.1' 1F A W bi SYSTEMS ARE MAN) ..z.. , LASE A(t 4 u ~C''; d .r a ~,-3 ~ EL:E f s,,,3r ;;3+ [9~, i gt[C?t IP, A L (FF'z t - . s - r , 3 . 1i1 AK E r} ti .,E st. o+(.r. .i< 1: oxkg in Jm i, s.dl a', ..ui:, zE. . W he r . d;;r~t k <3f,s;a 'ur!,h`.:t p,C.;i; f. 11''i EOcS. if ,!1 r. l ,t €a €ee.e ad f7s .,s ;3t" 3 ii gab?, W '.i xhni tM.id 3l wv r ,i ,'?fiuq: t€.t ya tr p u INN "m e A, 1 P, saw" on~ Lbi Con Q non 12 ;T SS So , U n - 50A V) W l VW s<= it s Lowny Sam! t c of o.'I i g, no v: -1VEE'a_' i . ON)" WW A _ , 400 0 9W e k ow III t J ~i• t~~ ~ 3 i 3 •8 4 ~ jC, L- Bpi a --j @?~tC~Rhtft-t~. d o >~IL P FtC aLN-rif ' ~y ~ R.M. FR.oM 1~5-^(qIL irv ELnn- ,.1 EL-av. ~oo.oo • sa:P rI'- Ti,, K(K Pfe-o t W^ - 14)"N4l/J/M(JMr r a4 , N a..... ~~'L~ ~IJti:::~*IT 71 ' I! 19 Y,a i4 3. P-3_r C "rk r . o SYST. EL F-Y. 14. SO 4" c i'E - , ~2on/ ~r~E 3 4"L^AST 12nN I' I FE a F %a z it PV P1 ` /000 faAL. SEPTtc- T'RN~ 14 Wisconsin Department of Industry, PLB-.If INSPECTION REPORT Labor & Human Relations Safety & Buildings Division Bureau of Plumbing, Platting & Fire Protection Name o remises Date an No. Street City County Sanitary Permit Master Plumber Firm Name dress Journeyman Plumber Address Owner Address - iscusse with Signature ( )See Attached. DILHR-SBD-6192(N.09/80) Signature o is Plumbing up. On-Site Waste Specialist bite-Inspector Yellow-Local Inspector Pink-Plumber or Responsible Party Green-Owner