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Wisconsin Department of Commerce SOIL AND SITE EVALUATION <br /> givision of Safety and Buildings Page of <br /> Bureau of Integrated Services in accordance with s. ILHR 83.09,Wis. Adm. Code <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. Parcel I.D.# <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 Property Location <br /> /L) /(j Govt.Lot 1/4 1/4,S1�2 Tdd ,N,R /6 E(or)6 <br /> Property Owner's Mailing Address Lot# Block# Subd.Name or CSM# <br /> 85-c) gad s <br /> City L State Zip Code Phone Number ❑ city ❑ Village Town Nearest RQad / <br /> (J C�itl �� G.1 703 ( ) /2J e`S /)/J� �l !_o{1n)Sa <br /> R'New Construction Use: esidential/Number of bedrooms Addition to existing building <br /> ElReplacement Public or commercial-Describe: —� <br /> Code derived daily flow gpd Recommended design loading rate > � bed,gpd/ft2 - eD trench,gpd/ft2 <br /> Absorption area required O 0 bed,ft2 s6V trench,ft Maximum loading design g g rate bed,gpd/ft'- trench,gpd/ft2 <br /> Recommended infiltration surface elevation(s) f&l, n(as referred to site plan benchmark) <br /> Additional design/site considerations v /L /I/YO- <br /> Parent material G 1A c- 1/� /'/ C! Flood plain elevation,if applicable /y Y n <br /> S = Suitable for system IConventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank <br /> U Unsuitable for systemi Os ❑ u I E's ❑ u ,mss ❑ u Ms ❑ u 23 ❑ U ❑ S ;�Icu <br /> SOIL DESCRIPTION REPORT <br /> Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/fl2 <br /> in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. Bed ,Trench <br /> 0_67 <br /> 77� p <br /> Ground <br /> elev. <br /> Depth to <br /> limiting <br /> factor <br /> Remarks: <br /> Boring # <br /> m <br /> s <br /> Ground <br /> elev. <br /> Depth to <br /> limiting <br /> factor <br /> ,>�in. Remarks: <br /> CST Name (Please Print) Signature Telephone No. <br /> Gr.� �lel.z. _�?-2'C <br /> Address Date CST Number <br />