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HomeMy WebLinkAbout030-1046-50-000 L n N O 3-0 n d ~1 C - 7 o 3 7 co m n A V y -(Du n ~ Ot fD 3 n o v z ° C. z r- j w `C j. 3 9 . s N o m o m m o o OM n Z n N CO Q N CD O co : N A G 1 0 (D L -i A O r~ O Cil 3 a 3 a) o o (n CD 0 m r m co m N a W m m 0- CD O CL „ N O CD co co cn C7 Z c , (D r+-- ~ ~ . Gv m < N III 0 0 0 P ~ ~ ~ ~ 3 v m - } ;t 3° v v v N 1 -._J p Ft (D m fD y 0 O a' m a CL r'. 1 Z Z W Q O O 7 D a ° lV _ N O cn N • lI m N N CD m m ~yy c N F. v d Z = A Z c N Z O 0 d A C 7 0. co V W ' O i CD 0 N Z 0 3 U 0 ;w O 3 `CD N x A < N W p~ N a CL cC.0 CL o = ` O • fD Z3 "n ~ ~ v C Q O Z d O d ~ N _ N 0 _ O d Q S O C 61 fi N 7 (D ~ W a m zt N A O CL N (D O N ' a 0 A 6p N O ~ da En O o, ° s 0 to O K T n v 0 0 LOP) w c r 0 v c -o 3 Co m 3 ftll 0 2 Ian ~ 2 ° • C7 O N ~r1? N a W O ]~rli z 0- CO O' N , O Z:71 - N co N w (D T, ` 11 N N N C)- 0 ~7 3 J Cti O O O Q (D O C) 0 0 -1 O0 N N N O (D CD a a N Q7 c c D o j 0 0 cn ts„r O O C P w es~ co <n CO CO N Rei N 00 co N N O N S O C* ~ < O O*C i Z Sr co y v m v 2. C) U) N CD N O Sp d 3 o (D - CD CD o N d o 3 ~ N Z CO Z D Q o oA N O !O , N "*A (D o N + a Co N c CD m a 3 _ ~ Z CA N O ~ ~ n ~ ~ Z^ 0 (n ~ N co v w CD CD O Q , N Z cn Z7 0 " : cp y a CD a w ~ CD CD s~ O o cD N (D (D cS?o~ v tn c 0 O ° o ° a a~ 6 Q N N (D Cl. v C a nE3 W o v c ~ ~(D a (D z (D o (A N N C W CL Q N CJ Q O ~ O D 00 C L~ K 7ti ~n Efl O ~ O S 1 O R7 May 17, 1999 Kathy Hildebrant 532 Valley View Trail Somerset, WI 54025 RE: House addition, Town of St. Joseph, St. Croix County Dear Mrs. Hildebrant: You have requested the Zoning Office to review your remodeling/addition project for compliance with the state sanitary code (COMM 83). When remodeling or adding onto a dwelling you are required to examine whether or not the construction involves an increase of wastewater. It is my understanding that the basement only is used for utilities. The current structure has 788 square feet of total living area and you are proposing another 361 square feet of living area. The proposed construction equals a 49% increase in the total living area and does include a bedroom. Section 83.055 (3)(b)(2) states: Increased wastewater load in dwellings results from an increase in the number of bedrooms from construction of any addition or remodeling which exceeds 25% of the total gross area of the existing dwelling unit. Since you are adding another bedroom and the construction/remodeling does exceed the 25% standard as stated in the code section above. The septic system will have to be evaluated to obtain a building permit. On April 21, 1999, Donavin Schmitt inspected your septic system and he noted that the system was functioning properly at that time and no surface water was evident. The as-built report revealed that the septic system is sized for a three-bedroom dwelling. Records of the sanitary permit are located in the Zoning Office. Donavin Schmitt installed a 1000-gallon septic tank and 18 foot by 54 foot absorption field on November 15, 1982. Since your proposal exceeds the 83.055 (3)(b)(2) standard, you must have an affidavit recorded with the Register of Deeds indicating that the addition may cause the existing septic system to become undersized for a dwelling of the resulting size. Also indicate whether a replacement area is available. Yni.1428fA« 266 EXISTING SEPTIC 6 3594 SYSTEM AFFIDAVIT KATHLEEN H. WALSH GISTER Document Number REST. OF DEEDS CRO CF:OI X CO., WI Name & Return Address RECEIVED FOR RECORD Kathy Hildebrandt 05-24-1999 8:00 AM 532 Valley View Trail SOMERSET WI 54025 AFFIDAVIT EXEMPT N CERT COPY FEE: COPY FEE: 21 . 3 0 . 19 . 17 4 E3 TRANSFER FEE: DING Parcel I . D . Number PAGES: FEE: 10.00 030-1046-50-000 Computer Number The existing septic system which serves the dwelling being added on to must be verified by an acceptable soil report or be inspected by a licensed soil tester for compliance with high groundwater and/or bedrock separation requirements as set forth in s. COMM Chapter 83.10 (2) WI. Adm. Code. The results of that inspection must be made available to this office. If the existing septic system meets these minimum requirements, and is properly functioning, an addition may be added to the dwelling without updating that system. This addition must not, however, encroach upon the required septic system setbacks as setforth in s- COMM 83.10 (1). Property Owner (s) Kathy Hildebrant Property Mailing Address: 532 Valley View Trail Somerset WI 54025 Property Legal Description: Lot # CSM/Subdivision SE 'a, SW sec. 21 , T 30 N-R 19 W, Town of Somerset Comments: The existing septic system was sized and installed for a three-bedroom dwelling. Donavi.n Schmitt stated in an inspection report on April 21, 1999, that the septic system was functioning properly. I, as the owner of the above described property, hereby affirm that the septic system serving this dwelling meets the above referenced state private sewage system codes. I realize that this addition may cause the existing septic system to become undersized for a dwelling of the resulting size, and 1 will make this information available to any future parties interested in purchasing this property. Signed CVtL Notary Public Subscribed and sworn to before me on lthis date: Date: Zoning DQ 1 t My commission eires: Approval Date: i 4A To prolong the life of the system, remember to have the septic tank pumped once every three years or when the tank becomes 1/3 full of sludge and scum. Other efforts to prolong the life of the system could be as simple as fixing or replacing plumbing fixtures with water conserving fixtures, reducing shower time, washing dishes when the dish washer is fill, avoid using a garbage disposal, using a wash machine with a suds saver feature, etc. Therefore, the prolonged life of this system may be dependent upon proper maintenance of the system. The property owner has met all the requirements of COMM 83.055 and can proceed to obtain a building permit for the proposed house addition. Should you have any questions, please contact this office. Sincerely, Rod Eslinger Zoning Specialist Parcel 030-1046-50-000 05/25/2006 04:27 PM PAGE 1 OF 1 Alt. Parcel 21.30.19.1746 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 O - BRAKKE, KATHLEEN A & GREGG W KATHLEEN A & GREGG W BRAKKE 532 VALLEY VIEW TR SOMERSET WI 54025 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 532 VALLEY VIEW TR SC 5432 SCH D OF SOMERSET SP 1700 WITC Legal Description: Acres: 2.240 Plat: N/A-NOT AVAILABLE SEC 21 T30N R19W S 1/2 SW 1/4 COM 468.5 Block/Condo Bldg: FT N OF SW COR SEC 21, E 1710 FT TO POB N 15DEG W 524 FT W 190 FT, S 32DEG W Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 231.8 FT, S 71 DEG E 178 FT S 48DEG E 21-30N-19W 387.3 FT TO POB Notes: Parcel History: Date Doc # Vol/Page Type 07/26/2001 652137 1687/480 QC 07/14/1998 582952 1340/101 TI 2006 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/07/2004 i Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.240 61,300 91,200 152,500 NO Totals for 2006: General Property 2.240 61,300 91,200 152,500 Woodland 0.000 0 0 Totals for 2005: General Property 61,300 91,200 152,500 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 138 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 ST. CROIX COUNTY WISCONSIN ZONING OFFICE p p b p u n ST. CROIX COUNTY GOVERNMENT CENTER wwr~( 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 May 17, 1999 Kathy Hildebrant 532 Valley View Trail Somerset, WI 54025 RE: House addition, Town of St. Joseph, St. Croix County Dear Mrs. Hildebrant: You have requested the Zoning Office to review your remodeling/addition project for compliance with the state sanitary code (COMM 83). When remodeling or adding onto a dwelling you are required to examine whether or not the construction involves an increase of wastewater. It is my understanding that the basement only is used for utilities. The current structure has 788 square feet of total living area and you are proposing another 361 square feet of living area. The proposed construction equals a 49% increase in the total living area and does include a bedroom. Section 83.055 (3)(b)(2) states: Increased wastewater load in dwellings results from an increase in the number of bedrooms from construction of any addition or remodeling which exceeds 25% of the total gross area of the existing dwelling unit. Since you are adding another bedroom and the construction/remodeling does exceed the 25% standard as stated in the code section above. The septic system will have to be evaluated to obtain a building permit. On April 21, 1999, Donavin Schmitt inspected your septic system and he noted that the system was functioning properly at that time and no surface water was evident. The as-built report revealed that the septic system is sized for a three-bedroom dwelling. Records of the sanitary permit are located in the Zoning Office. Donavin Schmitt installed a 1000-gallon septic tank and 18 foot by 54 foot absorption field on November 15, 1982. Since your proposal exceeds the 83.055 (3)(b)(2) standard, you must have an affidavit recorded with the Register of Deeds indicating that the addition may cause the existing septic system to become undersized for a dwelling of the resulting size. Also indicate whether a replacement area is available. To prolong the life of the system, remember to have the septic tank pumped once every three years or when the tank becomes 1/3 full of sludge and scum. Other efforts to prolong the life of the system could be as simple as fixing or replacing plumbing fixtures with water conserving fixtures, reducing shower time, washing dishes when the dish washer is full, avoid using a garbage disposal, using a wash machine with a suds saver feature, etc. Therefore, the prolonged life of this system may be dependent upon proper maintenance of the system. The property owner has met all the requirements of COMM 83.055 and can proceed to obtain a building permit for the proposed house addition. Should you have any questions, please contact this office. Sin ely, Rod Eslinger Zoning Specialist I SON/TT & SMSEXCAYATINS 586 Valley View Trail Somerset, Wisconsin 54025 (715) 549-6651 April 22, 1999 TO WHOM IT MAY CONCERN RE: Kathy Hildebrandt Property On April 21,1999, the septic system at 532 Valley View Trail, Somerset, Wisconsin appeared to be operating properly. No surface water was evident. I Donavin L. Schmitt MPRSW #221741 532 Valley View Trail Somerset WI 54025 l May 11, 1999 Rod Eslinger St. Croix C. Zoning Y 1 i 1101 Carmichael Rd. Sr cRaX~999 Hudson, WI 54016 z~,r~~~ KFK Dear Mr. Eslinger: " Here is the information you requested for my building permit. I have enclosed a diagram of the original portion of my house. The house also includes a 1954 addition which is virtually identical to the proposed addition, except the proposed "office" space is a laundry room downstairs. The proposed addition will be the second floor of that addition. The house is 175 feet from the town road. Sincerely, C>30 - Kathy Hildebrant 21 ' ` 1 J 532 Valley View Trail Somerset, WI 54025 April 27, 1999 ' ,Q~A Rod Eslinger s~' St. Croix Co. Zoning ~ti~+~~~ <<:,;; 1101 Carmichael Rd. Hudson, WI 54016 19 Dear Mr. Eslinger: I contacted Don Schmitt and asked him to write a letter including the information you requested. His letter is enclosed. If you have any further questions about my septic system, please contact him. A copy of my contractor's (Randy Bollom, Badgerland) sketch is also enclosed. Sincerely, Kathy Hildebrant u i J f F -73 .y t { - H tLDD--:t Sly- 65 33 th1r,, ~ov~ A) I> L C. 1 ca~ f ~sri tv~r i 1 303dU 3a 3tp '-2 l~ AS BUILT SANITARY SYSTEM REPORT OWNER/%i- a /'Lft TOWNSHIP ADDRESS , hex 4' ST. CROIX COUNTY, WISCONSIN. SUBDIVISION - LOT LOT SIZE_ _ PLAN VIEW Distances and dimensions tO meet requirements of H63 ~EKYTHING WITHIN 100 FEEL' OF SYSTEM t t ' _ r I di a e o th Arrow I SOLE:-- BENCHMARK: (Permanent reference Point) Describe: Elevation of vertica~,reference point: Slope at site SEPTIC TANK: Manufacturer: Liquid Capacity: Number of rings on cover Taanc -itianhole cover elevation: _ Tank Inlet Elevation: Tank Outlet Elevation: PUMP CHAMBER Manufacturer: Number of gallons _ _ -6 y - Numl~er of gal. pump set or a cycle gallons; tot=al ca aC it- of distribution lines gallon size of pump M__ gallon per minute horsepower brand name of puulp and model number Type of warning device HOLDING TANK: Manufacturer Number of gallons Elevation of manhole cover I'y )e of warning device _ SEEPA E PIT SIZE,: -Number--6-f_pi.ts i Feet dlauicter _ feet liquid d6pt seepage pit ln1et pipe-elevation bottom of seepage pTt _e1-evat~on feet . SEEPAGE BED SIZE: number of lines wLdth r Ieitl;tl1 Lite dcypth SEEPAGE TRENCH: width length PERCOLATION RATE ARAEQUIED AREA A BUILT - INSPECTOR_ _ DATED PLUMBER ON JbB LICENSE NUMBER PLB 67 State and County State Permit # aG w Permit Application County Permit # for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: Z24AIV7 / I % T, i-3A -J !"/'-/L /'S i LC B. LOCATION: S&" '/a 5i,-' Section 2/, T _a~ N, R-a E (or) W) Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township Si C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance Single family Z- Duplex No. of Bedrooms _3 No. of Persons. D. SEPTIC TANK CAPACITY Total gallons No. of tanks HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concreted Poured-in-Place Steel Fiberglass Other (specify) New Installation Replacement X Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate otal Absorb Areal sq. ft. New Replacement k Alternate (Specify) Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches Seepage Bed: X Length Width IS' '_Depth Vef " Tile depth (top) SC No. of Lines Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits Percent slope of land 7 °.ti` Z Distance from critical slope WATER SUPPLY: Private [,A Joint ❑ Community ❑ Municipal ❑ Owners name as listed on EH 115 if other than present owner: I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the Certified Soil Tester, NAME `/{l✓/ ti C /t/~i S i CVi1,,L / CL C.S.T. # other information obtained from .tryjz= S %fi Z- ~ner uilder). _ Plumber's Signature MPJ R^ Phone #,7/-,~ Plumber's Address St= r- PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. I ' r i . e m ,a Asa.. ....w «,~,~o 3 e-. ..,y...,_ P Ya _ =J.». .4. . e gym. e. ._e, _ _ ~-,«.i4.., m>. < 3 3 f I 3 Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY Date of Application I' it 11~ Fees Paid: State d County Da Permit Issued/Rejected. (date) ) x Issuing Agent Namei Inspection Yes No State Valid# Date Recd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 7/1/78 _NT RR CFIVF() ID DUS S 3 EPORT ON SOIL BORINGS AND SAFETY & BUILDINGS N. L82 = DIVISION LABOR a ZONING PERCOLATION TESTS (115) MADISOP.O. BOX 76 N W153707 HUMR LATI WhCE LOCATION: ECTIO OWNSHIP/Mi-1-1- MI 1. LOT NO.:BLK. NO.: SUBDIVISION NAME: J N/R/qp(o s/. 1o4 - COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: USE DATES OBSERVATIONS DE NO. BEDRMS.: COMMERCIAL DESCRIPTI)N: I PROFILE R TONS: ER LA ION TESTS: Residence ❑New ,Replace t j&- 3o . Z- pz~ ~c9r' ~.ryryt~ sot l SC C 0 RATING: S= Site suitable for system U= Site unsuitable for system .0340, Z_ C O / CONVENTIONAL: MOUND: IN-GROUND PRESSURE:SYSTEM-IN-FILOLDING TANK: RECOMMENDED SYSTEM: (optional) I I Cxl SOU XS ❑ U CIS ❑ U Cl S MT D S AU COAX Of a A'dAA,* If Percolation Tests are NOT re wired DESIGN RATE: SYSTEM EL V. 4 I If any portion of the lot is in the under s.H63.09(5)(b), indicate: I( Floodplain, indicate 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. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 6" r~r /~0 Of 04 Bt T''/) 5.-(/ /(0 ~N S 36~;~n CS B .rL i~ it !ot''/S• v220" n S; /.t/Pj)t .ti✓'F B- <6t~ Ll'f 7 ~~tr ~•~"Q/ /~'",r~rr S•`/~rZff"6A T I tr B- B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD t PERT D 2 PERIOD 3 PER INCH P 3lo / / L r o P- of of - P- r P P- PLAN VIEW: 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 slop. SYSTEM ELEVATION ` 0/1 O X X x x X A X 114u © o q ! ( t Rdl t \ ~r 9, G- a eesa c,./or y INew EE. u©,. h a~~. lt; it ej jF/ Well I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures methods specified in the Wisconsin Admimistrative 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: F .7 ADDRESS. / CERTIFICATION NUMBER: PHONE NUMBER optional): C S R E: J i DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester. DILHR-SBD-6395 (N. 03/81) I DEPARTMENTPF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 " BUREAU OF PLUMBING MADISON, WI 53707 ,CONVENTIONAL ❑ALTERNATIVE IS,,,, Planl D. Number. (If assigned) ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: x 7t t FREF. ON DATE: } y~ - 1 1 Y \ BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. ELEV.: CST REF. PT. ELEV. r n-, i _ rI 1 P/MP SW No.. County ermit Number. Narn a of Plumber\ iM ~ i SEP TIC TANK/HOLDING TANK: 7 S L 7- " f MANUFACTURER / LIQUID CAPACITY. TANK INLET ELE V.. TANK OUTLET ELEV. WARNING LABEL LOCKING COVER PRO DED: PROVIDED. YES LINO ❑YES LINO BEDDING. VENT D A.. VENT MATL HIGFI WAT'R NUMBER OF. ROAD. PR OPERTV WELL. BUILDING. VENT TO FRESH 117 / AL4RM f FEET FROM ~r ► / LINE 'Z A15,IV4ETj ❑YES C NO ❑ ❑ O NEAREST r DOSING CHA4BER: MANUFACTURER JBIEDDING: LIQUID CAP V ,P MODEL. PUMP,'SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED. PROVIDED ❑YES LINO i' ❑YES LINO ❑YES LINO GALLONS PER CYCLE: u 7 oNTROLSOPERATIONAL NUMBER OF PtTOPERTV wFLL BUILDING IVENTTOIRLIH (DIFFERENCE BETWEEN r%. FEET FROM I INE AIR INLET PUMP ON AND OFF) YES NO NEAREST SOIL ABSORPTION SYSTEM. Check the/Oil mo ure at th .depth of plowing FORCE T, a~n^rI TR MATERInL AND MARKING or excavation. (If soil can be rolled int a wire, onstruction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: _ 17 WIDTH JLENGT!Hr OOF DISTRPIPE SPACING; COINSIDE ITS LIQUID BED/TRENCH TRENCHES r ,I', ERi PIT DEPTH DIMENSIONS r u 0 7, PI II FILL DEPTH UST H. PIPE DISTR. PIPE DISTR. PIPE MATERIAL N STH NUMBER OF -PPHOPERTV WELL BUILDING. VENT TO FRESII Bf rn t IPIs ABOVE cpyER ET E Eti_ END P S FEET FROM ~ LI AIR l~ .C NEAREST--s /3 MOUND SYSTEM: Mound site plowed perpendicular to slope Check the to e of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound sy ems t snake certain that it ON REVERSE SIDE. SHOW ELEVA- eets tl7e'c"T1 edium sand. TIONS MEASURED. ❑YES LINO SOIL .'OVER TEXTURE PERMANENT MARKERS OBSERVATION VVE ILLS r' ❑YES LINO ❑YES LINO DEPTH OVER TRENCH BED DEPTH OVER TRENCED TH OF TOPSOIL ODDED SEEDED MULCHED. CEM EH EDGES J' Z I - ~f ❑YES NO ❑YES LINO ❑YES LINO PRESSURIZED DISTRIBUTION SY ~ EM: WIDTH LENGTH NO.OF PATERAT SP GRAVEL DEPTH BEPIPE FILL DEPTH ABOVE COVER . BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIF D E ANIFOLD MATERIALNO ITRDISTRPIPE DISTRIBUTION PIPE MATERIAL & MARKING FLFVELEVDIAPIPES DIA.'. ELEVATION AND DISTRIBUTION HOLE SIZE HOLE SPACING DRYLL COR ECTLV COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION PLANS _ ❑ ES NO ❑YES LINO OMMENTS: _ PERMANENTYFMAJ OBSERVATION WELLS: NUMBER OF PROF ERTV WELL: BUILDING: COMMENTS:---- FEET FROM ES NO ❑YES LINO NEAREST r_ Sketch System on Retain in unty file for audit. Reverse Side. ITLE SIGNAT .~~DILHR SBD 6710 (R. 01/82) ~ ~ctic~~ /5 ~vQT t D ^ L LY /3a TCI (3L 0 c CSC C>-AL .S , I-s1 w r C3!`/ c rT~~ r jf4u5c- i 1 e" CIO~ j , c c t _ r_L~ 4 • 1-3 fro to