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Wisconsin Dep6ruNnyt Safety and Professional Services Page_of <br /> Division of Industry Services <br /> SOIL EVALUATION REPORT <br /> In accordance with SPS 385,Wis. Adm. Code County <br /> Bd/NG <br /> Attach complete site plan on paper not less than 8 112 x 11 inches in size.Plan must include, <br /> but not limited to:vertical and horizontal reference point(BM),direction and percent slope, Parcel I.D. QS— <br /> scale or dimensions,north arrow,and location and distance to nearest road. <br /> Please print all information. Re ewe QDate p <br /> Personal information you provide may be used for secondary purposes Privacy Law,s.15.04 1 m . <br /> Property Owner /� �t / / Property Location <br /> ❑ <br /> ,Ovrn/C7T L.Du lr',�' Govt. Lot % S Jp T qq N R /5' E (or) <br /> Property Owner's Mailing Address Lot# 81ock# Subd. Name or CSM# <br /> 7111/D 60 CIAO lox /,Os <br /> City State Zip Code Phone Number ❑City ❑VillageTown Nearest Road <br /> S;ree/ bur sy87 Cay Rd 7" <br /> ❑ New Construction Use:❑ Residential/Numberof bedrooms Code derived design flow rate_GPD <br /> ❑ Replacement 1 Public r commercial-Describe: 6-1 r/ <br /> Parent material Grl c c;%C--� � v�4s1. 'Flood Plan elevation if applicable ft. <br /> General comments and recommendations: <br /> Boring# ❑ Boring /��/��� <br /> Sou¢ S.�t ❑ Pit Ground surface elev. ft. Depth to limiting factor/00 in. <br /> Soil Application Rate <br /> Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/Ft2 <br /> In. Munsell Qu.Az.Cont.Color Gr. Sz.Sh. <br /> *Eff#1 I *Eff#2 <br /> r <br /> S-dS 7,5 w 5/3 L A51 Z.•, A"Cr <br /> S-Loo 7.5-9R qlq D51 X1 <br /> ❑ Boring# ❑ Boring <br /> ❑ Pit Ground surface elev. ft. Depth to limiting factor in. <br /> Soil Application Rate <br /> Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/Ft' <br /> In. Munsell Qu.Az.Cont.Color Gr.Sz.Sh. <br /> *Eff#1 *Eff#2 <br /> "Effluent#1 =BOD,>30 5 220 m /L and TSS>30<1 /L *Effluent#2=BOD, >30 5 220 m /L and TSS>30<_150 mg/L <br /> CST Name(Please Print) S Signature CST Number 220 83 -3 <br /> Address Date Evaluation Conducted Telephone Number <br /> - q - zi3� <br /> SBD-8330(R04115) <br />