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Wisconsin Department of Safety and Professional Services Q <br /> Division of Industry Services <br /> SOIL EVALUATION REPORT Page of <br /> in accordance with SPS 383,Wis. Adm. Code <br /> County BURNETT <br /> Attach complete site plan on paper not less than 8 1/2 x 11 inches in size.Plan must <br /> include,but not limited to:vertical and horizontal reference point(BM),direction and Parcel I.D.07 06 .79'/7,1 9 ,�,F <br /> percent slope,scale or dimensions,north arrow,and location and distance to nearest road. c3/ pnn ol.2ooa <br /> Please print all information. vi wed,by Date <br /> Personal information you provide may be used for secondary purposes(Privacy Law,s.15.04(1)(m)). 1 4z��� ZQI 9 <br /> Property Owner Property Location C, '" q r-- <br /> p AL (�J Govt.Lot /1)& (LIIl4 S / T 3� N R / 7 E( W <br /> Property Owner's Mailing Address Lot# Block# Subd.Name or CSM# <br /> 15 <br /> City S ate Zip Code Phone Number L-- ity []Village ..Town Nearest Road <br /> //d 71 <br /> ElNew Construction Use Residential/Number of bedrooms Code derived design flow rate GPD <br /> Replacement /? Public or cpmme cial-Describe: <br /> Parent material G-�G /� / �/�/ � Flood Plain elevation if applicable /v/mot' ft. <br /> General comments ` <br /> and recommendations: <br /> Boring# El Boring —' <br /> Pit Ground surface elev. ft. Depth to limiting factor �'�� in. <br /> Soil Application Rate <br /> Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/f?- <br /> in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. `Eff#1 'Eff#2 <br /> 7,5YAtY6 - <br /> r- I� <br /> Boring# B >4oring <br /> ElPit Ground surface elev. ft. Depth to limiting factor / in. — <br /> -`t— Soil Application Rate <br /> Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF <br /> in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. `Eff#1 I -Eff#2 <br /> ®- 15 1a� 15 : -7 << � <br /> y �y/ f <br /> Effluent#1 =BOD >30<220 mg/L and TSS>30<150 mg/L 'Effluent#2=BOD <30 mg/L and TSS<30 mg/L <br /> CST Name (Please Print) Signature CST Number <br /> Wade Rufsholm �fe� 227691 <br /> Address or Date Evaluation Conducted Telephone Number <br /> PO Box 514,Siren,WI 54872 (715)349-7286 <br /> SBD-8330(R07/13) <br />