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Nfsconsar Depabrentof Commence, SOIL EVALUATION REPORT Page/of 2 <br /> Division of Safety and Buildings <br /> In accordance with Camnr 95.Yft Adm. Code <br /> Attach complete site Plan on paper not less than 8 712 x 11 irfrlres in size,Plan toast <br /> Include,but rot limited to:vertical and horizontal reference powd(BMS,direction and s'anod LD <br /> percent slope,scale ord'unensims.norfllarrow.and' 6 anddslmwetoneatestroad <br /> Please print all information. Revleyred by tete <br /> Personal information you provide may be used for secondary purposes(Pmacy law,s 15.04(1)(m)). <br /> Property ory <br /> Y L^cab=n <br /> Qfl' -w GoVL Lot 114 1/4 S 21 T N R17 E(or <br /> Property Owner's 'icing rens Lot# 1Bia3c# Srbd.Name or CSW <br /> IVII/ R-Z- I i �y�/yi5P2 5 <br /> City State Zip Code Phone NiCity ❑vaage Town Pfenarest Road <br /> F�r� �t� S (7l5 ) -211 Z 7 <br /> ❑ NewConstruction Use:❑ Residential l Number of <br /> ? Code derived desigru flow rate GPD <br /> (go Replacement A ❑ Publico Describe: <br /> Parent material n�laG'rj/ fr` Flood Pla41 elevalm if applicable fl- <br /> General <br /> General comments /1 <br /> and recommendations: Logr1 Cori(cy QN 4, 1 e f 0 U er r' <br /> .$off -fon VIn.iFrcofia'� <br /> A4fpO AS 3`4B.B - 6ro66ow 2&g,, y S,U�g 40 *A-1u0o5-ALAuG0 Go> /ev' <br /> BorhV <br /> © Boring# Pit Gmund sv(eo '7Jeetev. R Deph b krift iarlar 7& in. <br /> 1Fl Sot!Application Rate <br /> Horizon Depth Don*wd RW=Desor"ot TexYae S/ncenne Corawlence Boundary Roots GPD/W <br /> in. Munsell Qu.Sz. Cot Color Gr.SZ.Sh. •Etf#1 •Eff#2 <br /> o- Zti r, cy /v <br /> ❑ Boring# ❑ <br /> Boft <br /> ❑ Pit Ground su sUceelev. R Deplir lo6nilitg factor n. <br /> Soil Application Rate <br /> Horizon Depth Dominant Cel Redox Description Texhse SautYlxe consistence, Boundary Roots GPD1W <br /> in. Munsell Qu.SL Cat Color Gr.Sz.Sh- •Eff#7 •Eff#2 <br /> GST <br /> Effluententtt#d1n=BUD >30 4 220 mg(L and TSS>30<150 ngA. 'Effluent#2=BOD c 30 ffQ&and TSS<30 mglL <br /> (/6lw t) A. lI <br /> Address Dais Evaluation Catdicfed Telephone Number <br /> Z ZZZ© J401t N Ind 4k-t R S N 5-f7// 715--e1- 7a <br />