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Wisconsin Department of Commerce O R I PIIL EAv, ATION R 11 <br /> - Division of Safety and Buildings <br /> REPORT Page 1_of <br /> in accordance with Comm 85,Wis. Adm. Code <br /> County <br /> Attach complete site plan on paper not less than 8 1/2 x 11 inches in size.Plan must <br /> include,but not limited to:vertical and horizontal reference point(BM),direction and Parcel 1.6. <br /> percent slope,scale or dimensions,north arrow,and location and distance to nearest road. <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)). <br /> Property Owner / Property location <br /> MAr� /"r A'I�Q�R Govt.Lot 1/4 1/4 S� T 4� N R �� E(or)O <br /> Prope Owner's Mailin Address Lot# Block# Subd. Name S CSM# <br /> oSoq Lo�l �i7, s _ 5utw. r ww Y sE� 2s <br /> Ci Stat Z p Code Phone Number <br /> M 1 _C64 3'9 <br /> ❑City ❑Village .Town Nearest Road <br /> TJ ( > ��1155 4"' Av. <br /> New Construction Use:{>•Residential/Number of bedrooms 4E__ Code derived design flow rate O _ <br /> GPD <br /> ❑Replacement ❑ Public wcommercial-Describem 'D : <br /> Parent material� al fi Flood Plain elevation if a livable <br /> General comments <br /> and recommendations: <br /> Sys . 52 . 99.o <br /> Boring# ❑ Boring �J p <br /> ' Pit Ground surface elev._ I ft. Depth to limiting factor 17— —in. <br /> Soil Application Rate <br /> Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPO/ff <br /> in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. •Eff#1 'Eff#2 <br /> SWI/ s1 Zabk M✓ 5 2v f ,S 9 <br /> 2 6- i-4 1 sl 11,*b1z Airy 2e . 4 <br /> 2-36 5 tz 4 G2d s nrScl e abk Zoo . 2 . 3 <br /> I /J_ Boring# Jal Boring q2 <br /> l —I ❑ Pit Ground surface elev.—7. It. Depth to limiting factor�2 —in, <br /> SoilD/fon Rate <br /> Horizon Depth Dominant Color Redox Description Texture Scture Consistence Boundary Roots GPD/ff <br /> in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. 'Eff#1 'Eff#2 <br /> l2 94c 414 s1 <br /> 3 12.2.9 5-11C 9a CZpI$ n, , S e-I <br /> Effluent#1 =BOD >30<220 mg/L and TSS>30<150 mg/L Effluent#2=BOD <30 mg/L and TSS<30 mg/L <br /> CST Narq,5(Please print) Si nature CST Number <br /> 2ZSSSI <br /> Address <br /> Date Evaluation Conducted Telephone Number <br /> 27760 �� W31�tz W 1. 59 �,- 1 I-a Z <br /> 7rs- �- 4457 <br />