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Wisconsin Department of Commerce SOIL AND SITE EVALUATION Page_of <br /> Division of Safety and Buildings in accordance with s. ILHR 83.09,Wis. Adm. Code <br /> Bureau of integrated Services <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 A"") 'C_ <br /> percent slope,scale or dimensions,north arrow,and location and distance to nearest road. Parcel I.D.# <br /> r9 a�2 Y <br /> APPLICANT INFORMATION- 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)). Q $ q <br /> Property Owner Property Location /`-' r <br /> E Govt.Lot /t)� 1/4��1/4,S ag T yv ,N,R /-,57- E(or N� <br /> Property Owner's Mailing Atkiress Lot# Block# Subd.Name or CSM# <br /> S �1,1/ <br /> 0 e r r f tJa <br /> City State Zip Code Phone Number El city ❑ Vjl_is �Town Nearest °� <br /> �J e 6,7�er fel 1 <br /> ;8-New Construction Use: nResidentiall/Number of bedrooms - Addition to existing building <br /> (l Replacement c/ ❑Public or commercial-Describe: <br /> Code derived daily flow / -Sc7 gpd Recommended design loading rate e �bed,gpd* �trench,gpd ? <br /> Absorption area required C2O bed,ft2 �5 e? trench,ft 2 Maximum oesign loading rate .75 bed,gpd* f trench,gpd/ftz <br /> Recommended infiftration surface elevation(s) 9`✓- 95`�ft(as referred to site pian benchmark) <br /> Additional design/site considerations <br /> Parent material l 4C/ 4/ ��'/ �f Flood plain elevation,if applicable N ft <br /> S = Suitable for system Conventional Mound In Ground Pressure AT-Grade System in Fill Hd S Tank <br /> U = Unsuitable for system M-S El $}.S ❑ U Ms El X S ❑ U Jas El u �s �u <br /> SOIL DESCRIPTION REPORT <br /> e gConsistenceBoundDominant Color Mottles Structure GPD/fF <br /> Boring# Horizon Di^ Munsell Qu.Sz.Cont.Color Texture Gr.Sz.Sh. Boundary Roots Bed Trench <br /> 13 <br /> a 7-sY _s.-. <br /> Ground <br /> / eeelev.. <br /> —ft. <br /> Depth to <br /> limiting <br /> factor <br /> Remarks: <br /> Boring# 75 <br /> 3-3/ 75 jfo% <br /> Ground <br /> elev.� / <br /> Depth to <br /> limiting <br /> factor <br /> -2�zLin. Remarks: <br /> CST Name (P}}lea a Print) Signature Telephone No. <br /> Date CST Number <br /> t X� sig' G✓ Y�'7 / - - aff� <br />