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(4Z n <br /> Wisconsin Department of Sa a ervices , l Page of <br /> Division of Industry Services �, `,'�a J�. <br /> 7ML E TION REPORT <br /> In accordance with S S 385 Wis. Adm. Code County <br /> Attach complete site plan on paper of le in si e.Pla ust include, 13L`P h <br /> but not limited to:vertical and horiz ntal referenc i ent slope; P5cel I.R.,�_3 c�_/�_!S-3 03 -ovP-oid ooa <br /> scale or dimensions,north arrow,a d locate rest road. �!` U /Pt <br /> Please print all information. Reviewed by Date <br /> Personal information you provide may be used for seconds purposes Privacy Law,s.15.04 1 m)). �, 'Z/ Z/ <br /> Properly Owner Property Location El 21 <br /> /Y?OL r k Govt.Lot '/, '/4 S 13 T 3ta <br /> R /-7 E (or) W <br /> Property Owner s Mailing Address Lot# Block# Subd.Name or C <br /> �3�� /3/aCjt /3roc7/C/Z�l <br /> City State Zip Code Phone Number ❑City ❑Village Town rest Road 9396 <br /> Lv{b5f ev LvT ���s' Lrn[o/h rack J3���uk /20/ <br /> �r]New Construction Use: Residential/Numberofbedrooms 3 Code derived design flow rate �/S`0 GPD <br /> ❑ Replacement ❑Public or commercial-Describe: <br /> Parent material CId C 1 h r (fir t Flood Plan elevation if applicable ti/H ft. <br /> General comments and recommendations: <br /> s s. e-1 y 93,9 <br /> Boring# ❑Boring ��.5 <br /> Pit Ground surface elev. ft. Depth to limiting factor SO in. <br /> Soil A lication Rate <br /> Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPcatio <br /> In. Munsell Qu.Az.Cont.Color Gr.Sz.Sh. <br /> DIFe <br /> *Eff#1 *Eff#2 <br /> 0 7�sIR y/'' 3 6 <br /> l0- S <br /> i s a M s b/� ,., -7 1, 6 <br /> 3 s0 -3-6 7 S'1/Z'-//'1 13 w► G l� ► — <br /> s wt � 7 . 6 <br /> ® Boring# ❑Boring <br /> ®Pit Ground surface elev. ft. Depth to limiting factor s6 in. <br /> Soil A lication Rate <br /> Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/Fe <br /> In. Munsell Qu.Az.Cont.Color Gr.Sz.Sh. <br /> l <br /> *Eff#1 *Eff#2 a- f 7 SL/l7 3/� — /S 1 /� ,,-. ) C S 3 ►n . 7 /, ry <br /> LOY <br /> sfv-(vl 7,5- '1/? ' w,shie, r►-i r — <br /> *Effluent#1 =BOD,>30 s 220 m /L and TSS>30 s 150 m /L *Effluent#2=BOD,>30 5 220 m /L and TSS>30 5 150 m /L <br /> CST Name(Please Print Signatur /� CST Number <br /> �Q 141 11 l-e If S � -,-�14 d 73 yv4 0 <br /> kddress d'7760 h-,Y 3S Date aluation Conducted Telephone Number <br /> 4� )E-57-7 <br /> SBD-8330(R04/15) <br />