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Wisconsin Department Industry, SOIL AND SITE EVALUATION Labor and Human Relations <br /> TION ns 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 B 1/2 x 11 inches in size. Plan must County <br /> include,but not limited to: vertical and horizontal reference point(BM),direction and '6y,1"-L) 'e 7V- <br /> percent slope,scale or dimensions,north arrow,and location and distance to nearest road. <br /> Parcel I.D.# <br /> 4 r 33 <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)), <br /> Property Owner / 1 Property Locatiory <br /> c/L) e 6 5 c,N Govt.Lot JJ /4S� 1/4,S T `i ,N,R E(or� <br /> Property Owner's Mailing Address Lot# Block# Subd.Name or CSM# <br /> tld� lS Z <br /> city State Zip Code Phone Number Nearest Road p / <br /> i o G✓� �-y G ( ) ❑ City ❑e eVillJagoe^J® Town <br /> C -New Construction Use: SRosidential/Number of bedrooms Addition to existing building <br /> ❑ Replacement ❑Public or commercial-Describe: <br /> Code derived daily flow o30 o gpd Recommended design loading rate bed,gpd/flz trench,gpd/i$ <br /> Absorption area required l oO bed,ft2 trench,ft2 <br /> Maximum design loading rate_.4 S bed,gpc[M2�_trench,gpd/ft2 <br /> Recommended Infiltration surface elevation(s) ft(as referred to site plan benchmark) <br /> Additional design/site considerations —' <br /> Parent material Flood plain elevation,if applicable /V,4-r ft <br /> S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System In Fill Holding Tank <br /> U Unsuitable for system ;!Is ❑ U as ❑ u t 5S ❑ U cgs ❑ u 9S ❑ u ❑s ® u <br /> SOIL DESCRIPTION REPORT <br /> Boring# Horizon Depth Dominant Color Mottles Structure <br /> in. Munsell Qu.Sz.Cont.Color Texture Gr.Sz.Sh. Consistence Boundary Roots GPDHt2 <br /> Bed Trench <br /> Me f Me <br /> 1 o <br /> sun _Z211Z_,t r c 5 3r<d 2 , ,8 <br /> Ground <br /> elev. s � ' <br /> Depth to <br /> limiting <br /> factor <br /> Remarks: <br /> Boring# <br /> -G ,s �3/� <br /> now <br /> Ground B'�o ,� �/S s/8 S/"/f <br /> Depth to <br /> limiting <br /> fa or ✓ <br /> in. Remarks: <br /> CST Name (Please Print) Signature Telephone No. <br /> 'VFs/jol <br /> Address r Date CST Number <br />