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Wisconsin Department of Industry, pp IL AND SITE EVALUATION <br /> Labor and Human Relations r age of <br /> Division of Safety and Buildings 0 n Q�� m v n&erdance with s. ILHR 83.09,Wis. V 1 � I G I N A b <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 <br /> percent slope,scale or dimensions,north arrow,and location and distance to nearest road. parte D.# <br /> qa <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)). y /s 1 <br /> 71 <br /> Property Owner Property Location <br /> :r0d4 WRKDEN Govt.Lot 5 1/4 1/4,S 3 T q I ,N,R `6 E(4 <br /> Property Owner's Mailing Address Lot# Block# Subd.Name or CSM# <br /> 1Q 7Z ,S <br /> city State Zip Code Phone Number <br /> r O ( ) Near st Road <br /> , LAKEVIr ■ r 6, ❑ Ci mage Town <br /> New Construction Use: %Residents[/Number of bedrooms 3 Addition to existing building <br /> ❑ Replacement ❑Public or commercial-Describe: <br /> Code derived daily flow 4M gpd Recommended design loading rate -7 bed,gpd/ft2 --9trench,gpd/ft2 <br /> Absorption area required tA3 bed;ft2 50 tr ch,ft 2 Maximum design loading rate -7 bed,gpd/ft2 -g trench,gpd/ft2 <br /> Recommended infiltration surface elevation(s)_9-!. �1:r• q I-o ft(as referred to site plan benchmark) <br /> Additional design/site considerations <br /> Parent material' Flood plain elevation,if applicable NA ft <br /> S = Suitable for system Conventional Mound In-Ground Pressure I AT-Grade System in Fill Holding Tank <br /> U = Unsuitable for system S ❑ U WS ❑ U Nf S ❑ U I )ds ❑ U S ❑ U [—] s rR U <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 /> - R 4 �� H3 .7 . $ <br /> Ground ` rti- 7 ;- $ <br /> L <br /> RI�ft. <br /> Depth to <br /> limiting <br /> factor <br /> 7 in. <br /> Remarks: <br /> Boring# <br /> I <br /> Z Z S 3D K5 j . . 8 <br /> 3 30- DHS ( <br /> Ground <br /> elev. <br /> 91,-z-ft. I ki5" <br /> .D <br /> Depth to <br /> limiting a <br /> rutf for <br /> in. Remarks: <br /> CST Name Please Print) Signature Telephone No. <br /> Address����o � � W� Date CST Number <br />