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Wisconsin Department of Safety and Professional Services Page of <br /> Division of Industry Services C57--2.1 - 193 <br /> SOIL5T-.2( - <br /> SOIL EVALUATION REPORT • <br /> In accordance with SPS 385,Wis. Adm. Code County <br /> Attach complete site plan on paper not less than 81/2 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. <br /> scale or dimensions,north arrow,and location and distance to nearest road. <br /> Please print all information. <br /> f4rautiy <br /> / /r/ 181 t ' <br /> Personal information you provide may be used for secondary purposes(Priva9 Law,s:15.04(1)(m)).. <br /> Property Owner Property Location /' 0 42' <br /> /i�y7 �x'(2 Govt.Lot % % S ZU T 3, N R `(e E (or) W <br /> Proprty Owwne Mailigrddres� Lot# ' Block# Subd.Name or CSM# <br /> Cit /Sl D S/a a Zip Code Phone Number 0 City 0 Village [Town Nearest Road / <br /> 6�s�„ � J �1i I S?✓v!/ I (1��7' 9 I 1,t�n l I Ogk./..26iD PA.4 <br /> (-)'y y <br /> B9�ew Construction Use:e'Residential/Number of bedrooms 3 Code derived design flow rate (5 GPD <br /> 0 Replacement 0 Public or commercial–Describe: <br /> Parent material ()/.10:4St/ Flood Plan elevation if applicable ft. <br /> General comments and recommendations: <br /> i <br /> ❑Boring ' / <br /> / Boring# <br /> alit Ground surface elev.7 _ 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. .Sh. <br /> 1 57 Icy Z — Cis' d S � L) ZC) .9 / <br /> Z 9-as fzsr y �? , 4 /. <br /> ,-,,,•; - <br /> -‘) it)/ 4/4 , — / - F5 q S- .5= 'b , flt r S cis _ C — • <br /> ❑Boring , /,/ <br /> Z Boring# t Ground surface elev.2c ft. Depth to limiting factor C 4 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.S .Sh. <br /> 1.. <br /> •Eff#1 •E 2 <br /> (�( -4 Il 4S uZc? 9 1.7 `-1 l z — 1 <br /> 3 /3-Z)-. 1 S�� Y-S 3 L S CQ(J Jf :et, ' 1- <br /> _ 5- Gy-7Z / �I p '7�� r54 s G - - i.G <br /> •Effluent#1=BOD,>30 5 220 mg/L and TSS>30 5 mg/ •Effluent#2=BOD,>30 5 220 mg/L and TSS>30 s 150 mg/L <br /> CST Name(Plea),Print) �,, Signature ( CST Nu er1/Z3� <br /> Ad ress r , Dale Evalual du / Telephone Number <br /> -9J(r 31Cid< r�� e 7,5-_-)9,- 5/#2‘g <br /> W,6).(,r 0 S., 25,3 SBD-8330(R04115) <br />