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Wisconsin Department of Industry, SOIL AND SITE EVALUATION <br /> Labor and Human Relations Page of <br /> Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code <br /> Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County <br /> include,but not limited to: vertical and horizontal reference point(BM),direction and Aolj <br /> percent slope,scale or dimensions,north arrow,and location and distance to nearest road. Parcel I.D.# <br /> 524 of ?oo <br /> APPLICANT INFORMATION - Please print all information. Reviewed b <br /> Personal information you provide may be used for secondary purposes(Privacy law,s.15.04(1)(m)). Ap <br /> y I Date <br /> Property Owner Property Location `l7 CC//1�_ 9 <br /> Govt.Lot51/4 NW 1/4,S 174 T 3? ,N,R E(or W <br /> Property Owner's Mailing Address I Lot# Block# Subd.Name or CSM# <br /> F.o - Box 7-Ss qc <br /> City State Zip Code Phone Number ❑ City ❑ Village 12 Town Nearest Road <br /> SIREN WI 1,5ASa7 I I IS ) - 514511fLA LIC . 9R, <br /> New Construction Use: V Residential/Number of bedrooms 3 Addition to existing building <br /> Replacement ❑Public or commercial-Describe: <br /> Code derived daily flow 4EV gpd Recommended design loading rate1 bed,gpd/ft2- <br /> trench,gpd/ft2 <br /> Absorption area required 40q3 bed,ft2 S?.3 trench,ft21 <br /> Maximum design loading rate bed,gpd/ft2 •$ trench,gpd/ft2 <br /> Recommended infiltration surface elevation(s)—A.3-1 ft(as referred to site plan benchmark) <br /> Additional design/site considerations ,r <br /> Parent material G L ickjaL Rai f Flood plain elevation,if applicable N ft <br /> S = Suitable for system 1Conventional �MMoound In-Ground Pressure AT-Grade System in Fill Holding Tank <br /> VS U Unsuitable for system S ❑ U til S u Q S ❑ U IJKS ❑ u S ❑ U El tLy II <br /> SOIL DESCRIPTION REPORT <br /> Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2 <br /> in. Munsell Qu.Sz.Cont.Color Texture Gr.Sz.Sh. Consistence Boundary Roots <br /> Bed Trench <br /> 1 -INR 3 Let r S OS 1 <br /> Ground _ 4 (o SUS 05 1 — 7 <br /> Depth to <br /> limiting <br /> fa for <br /> 7 in. <br /> Remarks: <br /> Boring # <br /> _ t -b -1.5 '317- �- Is Os Nl <br /> �2 Z. (o-2Z ­511JE 4 uJ rellsd Ml '1 ,. Y <br /> 3 1: R 4 <br /> Ground <br /> Depth to <br /> limiting <br /> factor <br /> 7_7Zin. Remarks: <br /> CST Name (Please Print) Signature Telephone No. <br /> IC x}14" jhFXjd5 9"" !S-166- <br /> Address $ Date CST Number <br /> X77 s 1, °I3 - qq22SgS1 <br />