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Wisconsin Department of Industry, SOIL AND SITE EVALUATION Page / of� <br /> Labor andAuman Relations <br /> Division of Safety and Buildings in accordance with S. ILHR 83.09, Wis. <br /> County <br /> Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must 1( rJ <br /> include,but not limited to: vertical and horizontal reference point(BM),direction and <br /> percent slope,scale or dimensions,north arrow,and location and distance to nearest road. Parcel I.D.# <br /> u0%4;Z o — 9,3o 0 <br /> APPLICANT INFORMATION- Please print all information. Reviewed y A / Dat 3 / <br /> Personal Infonnatlon you provide may be used for secondary purposes(Pdvacy Law,s.15.04(1)(m)). 6-L / <br /> Property Owner - / Property Location c/ <br /> ;j p� U�JNSd/�' Govt.Lot 1/4 1/4,S T !U ,N,R �(p E(or)W <br /> Property Owner's mailing Address Lot# Block# Subd.Name or CSM f,�JJF.tJ <br /> !�� G <br /> .3o1`I, !�- �c�heJ! ilcf7 a�iS <br /> City State Zip Code Phone Number city d /age ® Town Nearest R ad <br /> form :ZJ ipCode 8 ( 7/S ) <br /> ❑ New Construction Use: ®Residential/Number of bedrooms Addition to existing building <br /> ❑ Replacement ❑Public or commercial-Describe: <br /> Code derived daily flow o O gpd Recommended design loading rate—be J,gpd/ft2_--. trench,gpd/ft2 <br /> Absorption area required _ bed,ft2 trench,n2 Maximum design loading rate bE d,gpd/f12 V trench,gpd/112 <br /> Recommended Infiltration surface eievati i - ft(as.referred to site an benchmark) <br /> Additional design/site considerations V o / d��N C 04/ <br /> Parent material Flood plain elevation,if applicable n <br /> S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank <br /> U = Unsuitable for system ®S ❑ u ® s ❑ u ®s ❑ u ® s ❑ u ®s ❑ u ❑ S ($u <br /> SOIL DESCRIPTION REPORT <br /> Horizon Depth Dominant Color Mottles TeMure Structure Consistent Boundary Roots GPDren <br /> Boring # Bed ,Trench <br /> in. Munsell Du.Sz.Cont.Color Gr.Sz.Sh. <br /> Ground <br /> 9alks d o yfr- e7 8 <br /> Depth to <br /> limiting %J8 7S`Yrl <br /> factor <br /> Remarks: <br /> Boring# <br /> 13 <br /> Ground <br /> elev.. <br /> Depth to <br /> limiting <br /> factor <br /> In. Remarks: <br /> CST Na a (Please Print) Signature Telephone No. <br /> Q7(Zc e— du, 7�r-CST Number <br /> umber <br /> NY <br /> Address' .7.� Date' J 7U <br /> 16 1r a?6') a41 e G ef C 'j-yas3 y- 6 - 96 <br />