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Wisconsin Department of Safety and Professional Services <br /> Division of Industry Services <br /> SOIL EVALUATION REPO T _ l� Page of <br /> in accordance with SPS 383,Wis. Adm. Code - ,I� <br /> Attach complete site plan on paper not less than 8 1!2 x 11 inches in size.Plan must County u n -e'f'� <br /> include,but not limited to:vertical and horizontal reference point(BM),direction and Parcel LD.O-7 0a0--X-`/a-//o-O7-S IS- <br /> percent slope,scale or dimensions,north arrow,and location and distance to nearest road. -5-$0 -p170 ov <br /> Please print all information. R vie ed by DD1ate <br /> Personal information you provide maybe used for secondary purposes(Privacy Law,s.15.04(1)(m)). �Aj — y 4 I I_ <br /> Property Owner / Property Location V tQ <br /> �Zib AM 01 v.fe Pf Govt.Lot 1/4 1/4 S 7 T Gj�j N R /& (r))W <br /> Property Owner's Mailing Address Lot# Black# Subd. Name or CSM# <br /> 0 99 Aw,X e t re/& 7 <br /> City State Zip Code Phone Number City n Village Town earest Road a96'7S- <br /> /v 3 t IAA 0 j i ( ) A) k/qn"; c//aw /Ztvrr kd- <br /> New Construction Useg Residential/Number of bedrooms j Code derived design Flow rate Zd0 GPD <br /> rl Replacement Public or commercial-Describe: <br /> Parent material e41e-r e, 7,�4 Flood Plain elevation if applicable /VZW fL <br /> General comments <br /> and recommendations: .J j'.S. e l�c✓ 9 3 r .r <br /> ❑ Boring# 11 Boring <br /> �G S- <br /> Pit Ground surface elev. ft. Depth to limiting factor 7 7,�_in. <br /> Soil Application Rate <br /> Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF <br /> in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. *Eff#1 *Eff#2 <br /> / o- 6 7.s�i�z3/ / j b !c I is m , 7 / 6 <br /> 6' sy 7S9rZ`'�9 ` 1n56le vim+ 1 �S 3ca 5 /•� <br /> Boring# n Boring <br /> M Pit Ground surface elev. S 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/fP <br /> in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. Eff#1 Eff#2 <br /> 6- 4 -75-17RJ/ Mdbl.,- l 3yn r7 f. 6 <br /> a Jr-0 7J`11?yl <br /> 3 (I/? 4 — F dri <br /> Effluent 41 =BOD,>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) Sig ture e CST Number <br /> w�(ti/rlfS s % G✓Ir� /S S / 7J <br /> Address y ` LZ Date Evaluation Conducted Telephone Number <br /> ����7�� 7 g,<13 -71--,'--*6 6-Yis7 <br /> SBD-8330(R07/13) <br />