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( <7-- ,-)1- Ig9l <br /> Wisconsin Department of Safety and Professional Services <br /> Division of Industry Services <br /> SOIL EVALUATION REPORT Page of <br /> in accordance with SPS 383,Wis. Adm. Code <br /> County BURNETT <br /> Attach complete site plan on paper not less than 8 1/2 x 11 inches in size.Plan must D b <br /> include,but not limited to:vertical and horizontal reference point(BM),direction and Parcel I.D. 0 <br /> percent slope,scale or dimensions,north arrow,and location and distance to nearest road. 712 <br /> Please print all information. Reviewed by Date <br /> Personal information you provide may be used for secondary purposes(Privacy Law,s.15.04(1)(m)). �, 7, <br /> Property Owner ` Property Location `/ J ElE4 <br /> /1-1.© /N )/+e s o ��/r/ Govt.Lot 1/4 1/4 S T y 0 N R I5 E(or)W <br /> Property Owner's Mailing Addre s Lot# Block# Subd.Name or-Q&W <br /> 41 �K yo �- odd A-d� f® V. V, <br /> City State Zip Code Phone Number i - e ty Villa g Town Nearest Road AY 7 <br /> 1�I �5�37�(95',Zi y8y- 2 �A� S o A) zL'm o.� 711 <br /> New Construction Use Residential/Number of bedrooms 3 Code derived design flow rate GPD <br /> Replacement Public or commercial- escribe: �— <br /> Parent material Flood Plain elevation if applicable <br /> General comments <br /> and recommendations: <br /> a19 Boring Boring# _ <br /> Pit Ground surface elev._yft. Depth to limiting factor >72 in. <br /> Soil Application Rate <br /> Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz <br /> in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. 'Eff#1 'Eff#2 <br /> y 7' 7 ZZ <br /> v2 / 7 <br /> 7-�`I� <br /> 3 -�7,Z 7,67A7,'6 / <br /> ® Boring# n Boring <br /> pit Ground surface elev. i / ft. Depth to limiting factor in. <br /> Soil Application Rate <br /> Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fg <br /> in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. 'Eff#1 I 'Eff#2 <br /> l o <br /> 02 s y/y 7 ms�� Sa /. <br /> 'Effluent#1 =BOD5>30:<220 mg/L and TSS>30<150 mg/L 'Effluent#2=BOD <30 mg/L and TSS<30 mg/L <br /> CST Name (Please Print) Signature CST Number <br /> Wade Rufsholm 227691 <br /> Address Date Evaluation Conducted Telephone Number <br /> PO Box 514,Siren,WI 54872 (715)349-7286 <br /> SBD-8330(R07/13) <br />