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Parcel 026-1087-40-000 06/07/2005 09:41 AM
PAGE 1 OF 1
Alt. Parcel 30.30.18.458G 026 - TOWN OF RICHMOND
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): * = Current Owner
* DURAND, PETER L & LORI A
PETER L & LORI A DURAND
1354 CTY RD A
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description ' 1354 CTY RD A
SC 3962 NEW RICHMOND
SP 7040 RICHMOND SANITARY DIST 1
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 1.020 Plat: N/A-NOT AVAILABLE
SEC 30 T30N R18W SW NE 1.02A LOT 3 OF Block/Condo Bldg:
CSM 5/1354
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
30-30N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 679/402
2005 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 06/30/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.020 27,000 139,500 166,500 NO
Totals for 2005:
General Property 1.020 27,000 139,500 166,500
Woodland 0.000 0 0
Totals for 2004:
General Property 1.020 27,000 139,500 166,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 217
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
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.
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: Oc `
PROPERTY OWNERS ADDRESS l , t t'(, - CITY 1 _ ~ a',~,, <<„•! c_; ~ ; I
Legal Description` . 1/4; 4, N~ .1/4, Sec. T -N-R i`W,
Town of Lot: No. Subdivisionc_ ,r,v Sj i3;y
FIRE NO. ('1# LOCK BOX NO.~ t
Color of house,; Realty sign? ~.c. Firm: -
CC I
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: ~_O
CLOSING DATE. ( y-v.?
Signature: 1 t\ iczvt-
~ 1.
1
'.r'c'vzl
V3'.
1 1
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
~ y ST. CROIX COUNTY COURTHOUSE
_ r
F"Tf 911 FOURTH STREET 0 HUDSON, WI 54016
(715) 386-4680
Feb. 11, 1992
Peter Durand
1354 Co. Rd. A
New Richmond, WI 54017
Dear Mr. Durand:
An inspection of the septic system on the property of Peter &
Lori Durand, located at 1354 Co. Rd. A, New Richmond, WI was
conducted on Feb. 11, 1992.
At the time of inspection, the sanitary system appeared to be
functioning properly. The inspection of this sewage disposal
system was based upon a surface inspection of said system, and
did not involve any excavating or chemical analysis.
Accordingly, there is the possibility of hidden defects in the
system not discoverable by this inspection. This does not in
any way warrant or guarantee the continued proper functioning or
operation of this system. It is recommended that the system
should be pumped once every three years. Therefore, the
prolonged life of this system may be dependent upon proper
maintenance of the system.
in ere1y,
dames K. Thompson
Assistant Zoning Administrator
cj
+ AS lil_! 1 L,'i' ANITA R.Y SYSTEM REPORT
OWNER POWNSIIIP ~rr< f J'r~ ~1 SNC. T 3,-N-Rl,!e, W
ADDN SS ST. CROIX COUNTY, WISCONSIN.
I
U R 1) IV I S 1.0 N LOT I' L o `L'
PI,AN VIEW
I) i_stances and C() meet requirements of 1-163
`;IIOW (?V RY'I'II I_NC W I TILL N 100 FEET OF SYSTEM
X
Indi at - N r h err w
t1~'NCHMARK: (Permanent reference Point) Describe:
I J eviitioii of vert:icaI reference point : 1QJ ` ope at site: °
I:I"LIC TANK: Mauuf -acturer: 1F6 Liquid Capacity:_j~d~y
dumber of Brings on. cover e;f Tank manhole cover elevation :1p7 "
a n lc 1: n 1 e t 1. 1 e v a t i n 'l'ank Out I_e t E Leva tion
I'uM.T' CHAMBER
Mzrnulacturer: Number of }Iallons
a cycLe gallons; Total capacity of
Numher o f l . pump set f or
Ii.strilYefC7_c)n fines gallon: size of pump head;
~al_ n per minute horsepower _;brand name of pump
zily 111 0de.1 numbs r e of warn _lig device
1) 1 NC 'CA Manufacturer Number of gallons
(•v• _ i_on oI malilhole cover
e o 1 w a r I I I_ n g (I e V l c e
I'I;i't\t, l? P SILI?; -Number of 1.)its- - feet diameter
1,L(Iu-i_d depth seepage pit inlet pipe-elevation _
L r,t_tom eepage, pit clevat -ion feet
;1 EI'AG1 D S I Z1,' 11 u1111) er. o C L fines- w:idttr - length the depth
I F:I'A( I? TR1NC,II: w_iclth length ckj So
AREA REQU7 RED_ AREA AS BUIL
1 11:'C -,L AT I ON I,AT1f T
LNSPECTOR i
I Az, PI UMBt,,R ON JOB
L 1 L; N 5( N U MB ER_,jP
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS
P.O. Br" '969 PRIVATE SEWAGE SYSTEMS DIVISION
BUREAU OF PLUMBING
MAE) ON, 1,11111 53707
Lid CONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number
El
Holding Tank ❑ In-Ground Pressure ❑ Mound Ilf ass
NAME OF PERMIT HOLDER. r DDRESS OF PERMIT HOLDER: INS E TION DATE:
Peter Durand RR#4, Box 100, New Richmond / /-/-Y.
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: CST REF. PT. ELEV..
SW Ne, T30N-R18W, Lot 3, Town of Richmond
Name of Plumber. MP/MPRSW No.. Come,, Sanitary Permit Number.
Gary Steel 3254 St. Croix 43679
SEPTIC TANK/HOLDING TANK:
MA NUF ACTURER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELE V.. WARN NG LABEL LOCK IN COVE
s~s / OV DED PROVI D
(r / YES ❑ NO ❑ NO
BEDDING: VENT D VENT MATIL - HIGH TER NUMBER OF ROAD: / PROPERTY W L: BUILDI G. TO FRESH
ALARM 14 FEET FROM LINE / IVENT Aw~rEr
❑YES ❑NO C
❑ Y NO NEAREST
DOSING CHAMBER:
MANUFACTURER 71 NG. LIOUID CAPACITY. PUMP MODEL PUMP/SIP M NUFACTURER. WARNING LABEL LOCKING COVER
PROV IDED. PROVIDED:
ES ❑NO / ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS O RATI A NUMBER OF PROPERTY WELL BUILDING. (DIFFERENCE BETWEEN FEET FROM LINE JVENTTOFRESH
AIR INLET
PUMP ON AND OFF) ❑YES, NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth plo Ing LFN(ITR DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction sh cease until F CE
the soil is dry enough to continue.) AIN
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH LENGTH NO OF DISTR PIPE SPACING COVER INSIDE CIA LIQUID
' TRENCH S M 1AL ,PIT
DIMENSIONS DEPTH
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIP DISTR. PIPE MATERIAL: NO. D NUMBER OF
` PROPERTY WELL. BUILDING'. VENT TO FRESH
BE LOW PIPE S ABOVE COVER ELEV INLET ELEV END ` PIPE uNE
FEET FROM AIR INLET'
(n I cL 2_-
NEAREST-►
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 FPERMAINENT MARKERS OBSERVATION WELLS
_ ❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCH BED F TH OVER TRENCH /BED DEPTH OF TOPSOI L
CENTER . SODDED SEEDED MULCHED
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH TRENCHES LATERAL SPACING G
L DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEVATION AND ELEV.. ELEV.. DIA.. ELEV.. PIPES. DIA.:
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
YES ❑NO ❑YES ❑NO
COMMENTS: 7MAhKEFI RMAN ENT OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE:
❑YES ❑NO ❑YES ❑NO NEAREST
Sketch System on coup 'file for audit.
Reverse Side.
SIGNATURE. TITLE. -
DILHR SBD 6710 (R. 01/82)
~Onsin APPLICATION FOR SANITARY PERMIT
1 L H R (PLB 67) ~1_~01'~ COUNTY
Narmenr Ov UNIFORM SANITARY PERMIT #
STRY, LG]BDR 6 HUTRn RELfiTlO fff~~~
nS - / / ry
-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 ER MAILING ADDRERV#/Oa
4f L, 12
Ta4
PROPERT LOCATION 1
V
`-i 1/4 C1/4, S .gyp , T 30 N, R/ (or) W TOWN OF: ,yd~-~ i✓
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED
K 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 :F?~ 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:
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):
3 Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name lumber (Print): Signatur fdff~/MPRSW No. Phone Number:
Plumber's Addr s: Name of Designer:
COUNTY/ DEPARTMENT USE ONLY
Signature f Issuing Agent:: Fee: Date: ❑ Disapproved
n ce U`~ 11 L~ Owner Given Initial
A Approved r 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.
Form - S T C 100
Owner of Property -~Y" 1
.Location of Property S -_~4, Section T 3b N R~ W
Township__ Q. C-1" ,A
Mailing Address ~6L~'.'-- _
Subdivision Name
Lot Number 3
Previous Owner of Property 1~a«lI 1'~Suf-ctneA
Total Size of Parcel T-
Date Parcel Was Created s, I~
Are all corners identifiable? Yes No
Include with this application one of the following:
.Certified Survey Map
.Deed
.Land Contract, or
.Other I:egal Document which describes the property
PROPERTY OWNER CERTIFICATION !
I (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 virtua of a warranty deed recorded in the Office of the
County Register of Deeds as Document No-3- -0/_ _ ; and that I (we) (/d ,5j /3Sy"
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an easement, to run with the above described property, for the
construction of system, and the same has been duly recorded in the Office
F
of the unt Reg4ter of Deeds, 'Poeument No.
514 N
ATU
RE
N6:
A
S14NATUAE OF CO-OWNER (IF APPLICABLE)
Zo./9/r/3 I
DATES ED DATE SIGNED
CERTIRED SURVEY /"SAP
S '/a N F 'N SEC. 30 7.-30N- R 19W
TOWN OF R)CHNOND~ ST. CROIX COUNTY W)SCONSIN,,
N S 89~ L-O- 57 q PK.':~ 5`~a.6 6 N E COR
B F R N 7- 5 E N MO1v 9,0 6 a. 99' II ER 7-S E N
gEE COUNTY MON.
.SURVI=YOR FOR UNPLAT_TE_D LA_N_p
TIE 5 TO ~
MONUmF-= N rs APPROVED
h ,
s 89'-21-a6w ~i OCT 0 519
83
o P.QB. ~
NO c/- 3 a 6 E S+T. cROIX COUNTY
P COMPQEHENSI
K. VE PARKS P
IANNI
O a SO- 0 AND ZONING C NG
OMMIi1EE
UNP 6O V E DATA
LAT -7"ED LAND % , o r6 CUR
OWN p (3~ o~ 1.03 ACRES±~ ro CHORD AZ aO?- 1-56
01
PLATTER !gyp y;FxG. 0 RlSqlnl .F ~ (b CHORD 33a..3~.I.'
~ toRC DIS -3,-3 S7.00
LET l G' RADIUS 1 6'j '
a6
b N 89'- a8 Q
wLL
ii8o a so. o o' Li 012
'06 -u Z
N . IA
9 / 13. i 8 C 1,,
p O a A C RE s± 3 a-31 ~n! CC Z
Q)' i XC. Illw 199.69 CH. LL -i L
e o s D,7-0 1- L4-aw
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0
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4 = R1cN L O = P/4" IRON P) P1; SET
? WT. 1.13 L(3./ LIN. FT.
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DESCJt11 TlU
A parcel of land located in the South Half (S1) of the Portheast
Quarter (FE-1 4 ) of Section Thirty (30) Tol,-:nship Thirty (30)
North, Range EiFhteen (18) ;Jest, Tov:n of Rich-ond, St. Croix County
t.]isconsin described as follo,::s:
Commencing; at the T]orth Quarter (F_) corner of said Section Thirty
(30), Thence South 89040'54" East 2062.99 feet; Thence South 250
31'26" ,est 1 98.44 feet; Thence South 89031'26" ,9est 50.31 feet
to the point of beginning; Thence South 25031'26" vest 186.40 feet;
Thence Southwesterly along a curved line having a long chord of
South 2711'56" West 332.34 feet, an arc distance of 335.00 feet;
and a radius of 5685 feet; Thence South 28052'26" ',lest 81.26 feet;
Thence South 89031'26" West 250.00 feet; Thence I:orth 27035'46"
East 400.00 feet; Thence T`orth 25031'26" East 200.00 feet; Thence
North 89031'26" East 250.00 feet to the point of beginning of this
survey. The above described parcel contains 133729.20 square feet
or 3.07 acres more or less excluding the road right-of-way.
SURVEYOR'S CERTIFICATE
I, Richard D. Booth, being a duly qualified surveyor, do hereby
certify that by order of and under the direction of Harry Durand,
I have surveyed and mapped the property described. The plat shown
on the sheet is a true and correct representation of the exterior
boundaries of the land surveyed and that I have complied with the
provisions of Chapter 236.34 of the Wisconsin Statutes to the best
of m- knowled-e and belief.
I- ~ ~,s
Richard D. Eooth
Registered Land Surveyor
Clear Lake, Wisconsin
August 15, 1983
V, V l
s f (il~~i;1~- r
e:; a APPROVED
z
CLFAI~ i r !
Y
OCT 0 51983
tiff, t E t COMPRENDI Y
3iVE twRICS RU.rw~4G
AND IOMNG COwerearrrt
-r -t 2 c f' 2
New Richmcr_d. A"isconsin X10'7
MOWN OF RICHMOND
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n
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e ~~~f",~•~-tom
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION R AN
BOX HUB AN RELATIONS PERCOLATION TESTS (115) MADISON WI 53707
(H63.09(1) & Chapter 145.045)
LOCATION: SECTION: TOW LOT NO.: BLK. NO.: SUBDIVISION NAME:
to 1/41/4 -3o /T36N/R1a(or)W -d- .3 -
Oy.ao O B UYER'S NAME: MAILING ADDRESS:
~JC ~h~
j- c, 1C' I1'16~ cd
1 -
USE DATES OBSERVATIONS MADE
NO. BEDR IS.: COMMERCIAL DESCRIPTION: ry~ I PROFILE DESCRIPTIONS: rPE R COLATION TESTS:
Residene Icy New ❑Replace RATING: S= Site suitable for system U= Site unsuitable for system •7
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
~s ❑u s ❑u s ❑u a s ~u a s K] u~
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.H663.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
'0M,MA-I r PROFILE DESCRIPTIONS
BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER Df= Tr--IN, OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- j 17 P~SJ /0 / Z °Q
N > igh "S g1 "I. &).S. - 5 .
00 _<5' eil 16 r)
B
"i ~0
/V 4 /u E,
B o s.
B-S
77-
B- 0
I PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER S- AFTERSWELLING INTERVAL-MIN. PERIOD t PERIOD 2 PERIOD 3 PER INCH
P_ 3~y 'C 3 6 4 C3
P_ z, 3 Ab 3 61 /111 1:1/
P- o 7 Z.
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 L b c~5
c)-rdVM6ri I10 ~~_d. a-6 Ii-5_
. _ko4-
fey s,
Si-A K& a M00
, C- -3
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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
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
CST SIGN U ~
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DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
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