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Wisconsin Department of Industry, SOIL AND SITE EVALUATION <br /> Labor,and Hunlan Relations A ^ ^ �9ft�of <br /> Djvision of Safety and Buildings in accordance with S. ILHR 83.09, Wis. Adm. Code (`,J) K I`.J; (n\ <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 a"AAAZ <br /> percent slope,scale or dimensions,north arrow,and location and distance to nearest road. P&Eel I.D.# <br /> a - 033co <br /> APPLICANT INFORMATION- Please print all information. Rev awed by Date/ 7O <br /> Personal information you provide may be used for secondary purposes(Privacy Law,s.15.04(1)(m)). I 4a <br /> Property Owner Property Loca n tA <br /> Q Govt.Lot 1/4 1/4,S I T ,N,R !Y E(o� <br /> Property Owner's Mailing Address Lo1� [&"rlbdNa�me or CSM# <br /> City Stat Zip Code Phone Number l❑ City ❑ Village 53 Town Nearest Road <br /> l5410 1 1c $-330SIS <br /> ❑ New Construction Use: M Residential/Number of bedrooms Z Addition to existing building <br /> Replacement ❑Public or commercial Describe: <br /> Code derived daily flow �?Qt? gpd Recommended design loading rate_ _bed,gpdHt2 $ trench,gpd/ft2 <br /> Absorption area required _bed,ft2 _trench,ft 2 Maximum design loading rate •, bed,gpd/ft2 - g trench,gpd/ft2 <br /> All ,I <br /> Recommended infiltration surface elevations) 71 /- ft(as referred to site plan benchmark) <br /> Additional design/site considerations <br /> Parent material�A )�ar ' ' Flood plain elevation,if applicable IV N <br /> 11 1f <br /> = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank <br /> S <br /> U = Unsuitable for system 4 S ❑ U QS ❑ U ® S ❑ U S ❑ U S ❑ U ❑ S ® U <br /> SOIL DESCRIPTION REPORT <br /> Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence BoundaryjRootsr, Tr;ench <br /> in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. <br /> 1 l p- 7sr 2 r� s a ,f�, �s <br /> too <br /> Ground <br /> v. <br /> Depth to <br /> limiting <br /> factor Ell <br /> >4wn. <br /> Remarks: <br /> Boring # S .0 J CS 7 <br /> ms <br /> 2 <br /> Ground <br /> e <br /> /ft. <br /> Depth to , <br /> limiting <br /> factor <br /> 27tin. Remarks: <br /> Signature Telephone No. <br /> CST Name (Please Print) / <br /> w +-rl 14, <br /> Date r CST Number <br /> Address _ <br />