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Parcel 038-1160-10-000 05/26/2006 12:22 PM
PAGE 1 OF 1
Alt. Parcel 34.31.18.752 038 - TOWN OF STAR PRAIRIE
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
O - WOLD, DAVID B & DEBRA J
DAVID B & DEBRA J WOLD
1833 110TH ST
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ' 1833 110TH ST
SC 3962 NEW RICHMOND
SP 1700 WITC
Legal Description: Acres: 1.790 Plat: 1974-GERMAIN & HANNER ADD
SEC 34 T31 N R1 8W GERMAIN & HANNER ADD Block/Condo Bldg: LOT 11
LOT 11
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
34-31N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 790/448
07/23/1997 667/153
2006 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/12/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.790 30,500 125,900 156,400 NO
Totals for 2006:
General Property 1.790 30,500 125,900 156,400
Woodland 0.000 0 0
Totals for 2005:
General Property 1.790 30,500 125,900 156,400
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 212
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
AS BUILT SANITARY SYSTEM REPORT
OWNER ~ii,~ TOWNSHIP SEC.iT,N-R/TW
ADDRESS C- - 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
i _ti
1/7
I di at N r h rr w
Lj- VE
BENCHMARK: (Permanent reference Point) Descri < ~,`f! 4D711~
Elevation of vertical reference point: %cSlope at site:
SEPTIC TANK: Manufacturer / / ,)Liquid Capacity '
Number of rings on cover Tank manhole cover elevation: ~I-'-
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 seep-ge pit elevation feet.
SEEPAGE BED SIZE: number of lines _ width '-length -tile depth
SEEPAGE TRENCH: width length
,
PERCOLAT CON RATE_ AREA REQUIRED; AREA AS BUILT ~
INSPECTOR
DATED j 31 PLUMBER ON J/ > C;
EK
LICENSE NUMB
DEPARTMENT OF'INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BQX 7969 BUREAU OF PLUMBING
MADISON, WI 53707
XX CONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number
lf assigned)
❑ Holding Tank El In-Ground Pressure El Mound (
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER. INSPECTION DATE: /r
David wotd 26 Wtittiaw Ave, New Richmond, W1 lp,-V/ g3
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. own (p REF. PT. ELEV.: CST REF. PT. EL V.
NW SW, Sec. 34,T31N-R18W, Lot 1 1 ,G. Hannon Addition St. P&aiAie
Narne of Plumber: IMP/MPRSW No. Count, Samtary Permit Number:
Cad. Powen6 1563 St. Croix 43652
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY: TA K INLET ELE V.. TANK OUTLET ELE V.. WARNING LABEL LOCKING COVER
QC~ a PROVIDED PROVIDED
G t {Ji. L1 l L7 YES ENO ❑YES~ ENO
BEDDING: VENT DIA ENT ATL. HIGH WATER NUMBER OF ROAD. PROPERTY WELL BUILDING: VENT TO FRESH
ALARM - LI E _ AIR INLES
FEET FROM
EYES ENO ❑YES~-ENO NEAREST
DOSING CHAMBER:
MANUFACTURER BEDDING: LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED
EYES ENO EYES ENO EYES ENO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. JNUMBER OF PROPERTY WELL BUILDING I VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) DYES ENO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing ENGTH JDIAMETER 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 SP(+CING. COVER JINSIDE DIA. #PITS LIQUID
BED/TRENCH V, TRENCHES f WA ERIAL. PIT DEPTH.
DIMENSIONS
GRAVEL DEPTH FILL DEPTH IDISTR PIPE DISTR. PIPE DISTR. PIPE ATERIAL. NO. DI TR NUMBER OF PROPERTY WELL. t BUILDING. VENT TO FRESH
BELOW PIPES AB,WVE COVER FL8~ NILE V E `'7 'N c-/ PIPE` FEET FROM L~N E,:, AIFi rN LET.
ly; yl~(yhIr' ~ /t NEAREST-------y- v - !
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 RERSE SIDE. SHOW ELEVA-
meets the criteria for medium sand. TION MEASURED.
EYES ENO
SOIL COVER TEXTURE 5 PERMANENT MARKERS OBSERVATION WELLS
EYES ENO EYES ENO
DEPTH OVER TRENCH BED DEPTH OVER TRENCH, BED _ DEPTH OF TOPSOIL SODDED ISEEDII, MULCHED.
CENTER EDGES
EYES ENO EYES ENO OYES ENO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH NO. OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER.
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANI OLD NlTERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEVATION AND ELEV.. ELEV.. DIA. ELEV.-. ✓PIPES. DIA.:
DISTRIBUTION I VERTICAL LIFT CORRESPONDS TO APPROV ED
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL
PLA NS
❑Y S ENO EYES ENO
OP 1 ERTV WELL: BUILDING:
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PR E
FEET FROM LINE:
EYES ENO EYES ENO N AREST
~Z
Sketch System on Retain in county file for audit. ,
Reverse Side. f
SIGNATURE TITLE.
DILHR SBD 6710 (R. 01/82)
wlscor-sin APPLICATION FOR SANITARY PERMIT ,
COUNTY
(PLB 67)EUNIFORM SANITARY PERMIT #
OEPRRlTT 1EnT OF IMIDUSTRV, LRBOR 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%x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PR9P,ERTY OWNER MAILING ADDRESS
PROPERTY LOCATION CITY:
VILLAGE:
1/4 1/4, S T N, R E (or) W TOWN OF: %
LOT NUMBER JBNAME 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:
Z New System ❑ Tank Replacement ❑ Repair
❑ Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System Ll Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
Z 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 -
El 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. l
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 El Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of fie private sewage system shown on the attached plans.
Name of Plumber (Print): ~i'g"nature: i, MP/MPRSW No.: Phone Number:
Plumber's Address: Name of Designer:
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
~f' / L ❑ Owner Given Initial
k 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.
Furui - 5 1' C 100
Owner of 4'roperty3~%~j7 v/~ t!'J~~~
LocaClUr1 of Property S,
~yd ~ =4 , S e c t i u n 1' N !Z_ t.1;;' W
Town ehlp
Mailinb Address / -
5ubdivlaian Name ~
Lot Number/
Previouu Owner of Property . Iwo
T U L U I Size of P4rcel__~7f Yq
Dale. Parcel W4t► Created
Are all corneru identifiable? ~ yes No
inClude witli this applLcaClun one of the fulluwl_u ;
.Certitled Survey Map
.Deed
.Land Contract. or
.Other Legal Document which deucribeu Lite pruliurty
PROPERTY OWNER CERTIFICATION
(We) certify that all statements on this tOfM 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 of a warranty deed recorded in the Office of the
County Registur of Deeds as Document No."~j'S ; and that I (we)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an pavement, to run with the above described property, for the
construction of said system, and the same has been duly recorded in the Office
of the County s Reti i ~te
r of Deeds - 3 ~
, as Do rnent No.-~
L--64EY1GATUHE OF OWNER v6 AE OF C WNEA (IF APPLI~ L k
NATU
DATE NED DATE SICt ED
TE I r~ - -
- ..,rn~.aorw.. ,.,.•wir4x~abxs:. ,Ww..:.. „1...~.,w.~.azu:k.. Ld,~,. m;4cKa~. ..,...o-~C.d7u.~,..#~`mtz+Fa,Bausw:..w,u ~ l' il~a+++Hlk~i
GERMAIN AND ANNER ADDITION
LOCATED IN THE NW 1/4 OF THE SW 1/4 AND THE SW 1/4"
OF THE SW I/4 OF SECTION 34, T31N, RI$W, TOWN OF STAR
PRAIRIE, ST CROIX COUNTY, WISCONSIN.
r= . ~ . ' LFC,FTID
0 COUNTY SECTION COUNF.R MONUMENT FOUND, 9F RN ^;EN CAP
• 1 1~ PIPE WF(+1FNG 168 LOS/ LINEAL FT FOUND
0 2~XJd' IRON P!PE WEIGHING 363 L85./LINEAL FT. SET
~Sa ALL OTHER LOT CORNERS STAKEO WITH I X24 IRON PIPE WEIGHING 165LFlSiUNEaL Ft
SCALE IN FEET
200 lod 0 IDV 200
CURVE• DATA TABLE
by _-7
*>h pJ yr LOT RADIUS CHORD I CHptO ,FNTa.L
1 NO NO L'TH LENGTH EL A4 N 4'Y,,LE bf R',"
1-2 II 23]00 9_34 S2%w, __48'0000 __`_h9O 5J 56 h'
NOTE ALL LINEAL MEASUREMENTS HAVE AFP MADE TO THE NEARE51 Cr.lr HI.Rl,4F_;'i I;
.=`b.. OF A FOOT, ALL ANGULAR MEASUF+E"ENTS HAVE BEEN MA,IE TO ?HL ;LA'.L
TWENTY SECONDS AND COMPUTED TO THE VALUES SHOWN
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s
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417 CO N P9"49'40 E
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s
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KWMER LANDFILL
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jolit f w, Lot
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f p
_.,y fi I I~ is NQT E't OTS !AND 2, LOTS 3 AND 4, LOTS 5nND6, LOTS
9 4ND 10, AND AL 50 LOTS It AND 12 ARE HEREBY
RESTRICTED TO THE CONSRUCTICf4 AND U,E OF A
SWC,-E DRIvEWG~ TO SERb'E THEIR A0jO;',:!,r LOTS
t _ z t• ON AN FATENS,^N Cf THEP CCF?tiC,N LOT LINE
4'rI - 7~ y WiTHi.N THE LIM,TS OF EXISTING TP.SN ()AD P.GHT-
> OF-WAY THE 20 WIDE URI'JEWAY FASEYENTS
pi U-LT- SNCNVN ON TNIS PLAT ARE HEREBY GRANTED TO
• _ I1-N, U > u 3 ALLOW FOR THE MEPGNG OF THE IND!v IDUnL
{ A I I II X O- DRNwAr5 INTO A SINfLE C"'!EW'•:Y PaITIa TU
TEPP4, Uj" EXISTING TOWN RC4;1 ::'CyIT-OF-
I('1~'a 1 a EN
I •y r 1 'K'AV ~i
Li LJ
PSCONSIN REAL ESTATE TRANSFER RETURN Wisconsin Department of Revenue
RANTOR: GRANTEE:
ame Eduard Germain - John Hanner Name David and Bebbra Wold
3cial Security Number (Voluntary) L I I I Social Security Number (Voluntary) L I I
ill Address - New address if property transferred was residence Full Address
RR 1, Box 120S 126 Williams Ave
S
omerset, Wisc hew Ricbmond, Wise, 54017
54025
grantor related to grantee? Relationship includes, Name and address to which tax bills should be sent if not the same as above
arriage, blood relative, partner, lessee-lessor,
owner, parent corporation or joint owner. ❑ Yes ❑ No
-antee is Individual ❑ Partnershi ❑ Cor oration Other
~Iephone: Grantor ( 15 2 53 12 Telephone: Grantee ( 15 1 246-4035
>RT 1 - PROPERTY TRANSFERRED
ieck proper box and enter name of municipality and county Street address of property transferred include road name and/or fire number.
❑ City ❑ Village Town of: Star Prairie Vacant lot on Woodland Rd
County of: St Croix
gal Description (Fill in complete legal description in space below or if metes and bounds description attach 3 copies of it as shown on the instrument of
conveyance. If certified survey map number is used in description list town, range, section and acres.)
Lot No..11.Blk No...."'...Section3A.... Town 111... Range AWat Name.qerma.in.... nd ....Han!ner.... id ti:on....t.o...Star
Prairie
Property Parcel Number
RT 11 - PHYSICAL DESCRIPTION AND INTENDED USE
Kind of Property b. Residential Units, if any 2. Principal Intended Use 3. Land Area and Type Estimated
a. Yand Only ❑ One Family a. CKBesidential d. ❑ Agricultural a. Lot size (Jr x 7 L! s- ~J❑
❑ New Construction ❑ 2 and 3 units b. ❑ Commercial e. ❑ Recreational b. +]T_ Total Acres ❑
❑ Building Previously Used ❑ 4 or more units c. ❑ Industrial f. ❑ Other (Explain) 1. Tillable Acres
❑ Solar Design c. ❑ Rental
2. W.T.L. Acres
❑ Earth Sheltered Home 3. F.C. Acres
❑ Condominium
c. Ft. of Water Frontage ❑
>,RT r III - TRANSFER (Answer as many as apply)
®.Sale 2. ❑ Gift 3. ❑ Exchange 4. ❑ Deed in satisfaction of land ccntract -What was the date of the original land contract?
❑ Other transfers (Explain below) 6. Ownership interest transferred ❑ Full ❑ Other (Explain below) 7. What is the amount of mortgage assumed
grantee? $ 8. Does the grantor retain any of the following rights: ❑ Life estate ❑ Easement ,None
RT IV - COMPUTATION OF FEE OR STATEMENT OF EXEMPTION
Total value of REAL ESTATE transferred (purchase price, etc. rounded to next even hundred. Do not include personal property) s 7 500.oo
Value of personal property transferred but excluded from line 1 . . . . . . . . . . . . . . . . . . . $ -0- _
Value of tax exempt property (solar, wind, waste treatment, mfg. M&E, other) includes in line 1 . . $ -0-
TRANSFER EXEMPTION NUMBER if exempt for Reasons 1-13 (see instruction).... Sec. 77.25. ( -a- )
Fee - thirty cents per one hundred dollars of value (line 1 times .003) (Make check pay able to Register of Deeds) $
FIT V - CERTIFICATION
transfer must be reported regardless of the Grantor's state of residence. Information on this return will be used to administer Wisconsin Income and Franchise
Laws. Disclosure of the social security number is voluntary.
declare under penalty of law, that this return (Including any accompanying schedule) has been examined by us and to the best of our knowledge and belief it
ue, correct and complete.
Signature of Grantor or Agent Date Print or Type Agent's Name
3N
R E Signature of>Grantbe or Agent Date Print or Type Agent's Name
Document No. Vol. (Reel) Page (Image) Date Recorded Date and Kind of Conveyance
AVE 385594 667 153 6/24/83 5/25/83 LC
H/S Parcel Number 19 19 - Code: County Tax District Assm't Dist
,REA L L
ANK I I 1 Office 2 Field 3 Use 4 Reject
A B C D E Fi T T Ratio Consideration
500 (R. 11-8 1)
School District No. PROPERTY OWNERS COPY
DU TRY OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, G DIVISION
P.O. BOX 76
LABOR AND PERCOLATION TESTS (115) MADIS
ON WI 53707
HUMAN RELATIONS
(H63.09(1) & Chapter 145.045)
LOCATION: SECT ON: TOWNSHIP/Mf1N CIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
~/a (or)W - nl
COUNTY: OWNER'S/BUYER' CIE: MAILING ADDRESS:
l~ ,a f y J
USE DATES OBSERVATIONS MADE
NO. BEDRMS": COMMERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence / d New ❑ Replace - / ?
AJ ~
,r
RATING: S= Site suitable for system U= Site unsuitable for system /I t i
CONVENTIONAL: MOUND: IN_ -GROUND-PRESSURE: jSY:S]TE M -IN-FILLHOLDING TANK: RECOMMEND SYSTEM:(optional)
S DU Z S DU S DU S U D S CCU
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
plain, indicate Floodplain elevation:
under s,H63.09(5)(b), indicate: Flood
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_ /
r
B-% Vii-
PERCOLATION TESTS/ 7
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHE AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERT 2 PER D3 PER INCH
y
P- dQA11
P- 3 Z 41_1A1_!:
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 a show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope. 'j~ r~
SYSTEM ELEVATION' y~ l
~7 ~s 8 - - - 11 1
-T
I 3
z
i 4
,
,
0
_ _ , . x . _
~L- ST
gal . _ : 34'
78
I, the undersigned, hereby certify that the soil t is reported on thisorm were made by mein a with the procedures al~eds specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of in wledge and belief.
NAN,E print): i TESTS WER OMPLETED ON:
~ , 4 iell - Z_ S. ?
ADD S r CERTIFICATION NUMBER: PHONE NUMBER (optional):
_rL
CST SIGNATU E:
/
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