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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. <br /> Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must Coun'�, <br /> include,but not limited to: vertical and horizontal reference point(BM),direction and i9•f�/�f <br /> percent slope,scale or dimensions,north arrow,and location and distance to nearest road. Parcel I.D.# <br /> OJ y -45-z -7 - 0/Y" <br /> APPLICANT INFORMATION- Please print all information. Reviewed Date <br /> /! 7�Personal information you provide may be used for secondary purposes(Privacy Law,s.15.04(1)(m)). 7 <br /> Property Owner Property Location <br /> �X42-A-),6 fT 0-,e_ Govt.Lot c3-LO 1/4A,4Le 1/4,S ? T ,N,R E(or)W <br /> Property Owner's Mailing Address 72 Lot# Block# Subd.Name or CSM# <br /> i792F Ale-w .`f-7'- cv2J <br /> city ^dH StateZip Code Phone Number �i�Q' V Nearest Road <br /> ✓ ,�/ ���6 (�L) Y o ❑ City LJ Village RI Town <br /> b` ew Construction Use: RfResidential/Number of bedrooms Addition to existing building <br /> ❑ Replacement v ❑Public or commercial-Describe: <br /> Code derived daily flow 5TQ gpd Recommended design loading rate +—bed,gpd/ft2 —= trench,gpd/ft2 <br /> Absorption area required bed,ft2 —r trench,ft Maximum design loading rate bed,gpd/ft2 "- trench,gpd/ft2 <br /> Recommended infiltration surface elevabon(s), '�` L It(as referred to site plan benchmark) / (` <br /> Additional design/site considerations �o%1/ g 76w /t �7 S �S eh ohe ClUur'1«b1e J <br /> Parent material Flood plain elevation,if applicable it <br /> S = Suitable for system Conventional ,�M,.o{und In-Ground Pressure AT-Grade System <br /> rinbFill Holding Tank <br /> U = Unsuitable for system ❑S XU �I S ❑ U ElA S U ❑ S MU ❑ S �$U [:Is zU <br /> SOIL DESCRIPTION REPORT <br /> Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 <br /> in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. Bed Trench <br /> bit <br /> Ground J� 5 IC �� C C -Q k �it= ,j <br /> t Depth to <br /> limiting <br /> dti5 factor <br /> Remarks: <br /> Boring# <br /> ab <br /> 3 �0 7S't� s�� �1-1-74 7e <br /> Ground 30 oLix 5/ 7. S"je Vi ,S•"C o?,�,, —" Irl R <br /> Depth to <br /> limiting <br /> factor <br /> f1 in. Remarks: <br /> CST Na (Please Print) Signature Telephone No. <br /> ae u 6 n�� ��� .T- Y7z-RY*, <br /> Address Date CST Number <br /> /le/S .24 0 ve9'r3 7- 2 f- 9` J 7 a V <br />