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Wisconsin Department of Commerce SOIL EVALUATION REQ I G I N A Lge_of_ <br /> Division of Siafety and Buildings O ` <br /> in accordance with Comm 85,Wis. Adm. Code POT <br /> County <br /> Attach complete site plan on paper not less than 8 1/2 x 11 inches in size.Plan must z„ ,.�e' <br /> include,but not limited to:vertical and horizontal reference point(BM),direction and Parcel I.D. <br /> percent slope,scale or dimensions,north arrow,and location and distance to nearest road. 0 g - o a <br /> 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 /> Properly Own Property Location G. <br /> // <br /> 27 1(-� )4- t 7' / a Govt.Lot s67-1/4/t/�-1/4 S Oj T �F N R E(or W <br /> Property Owner's Mailing AddressLot# Block# Subd.Name or CSM# <br /> aS 6 <br /> CityII -- State Zip Code Phone Number ❑City E]Village own Nearest Road <br /> 16) C-b rer I 1J-T 1 Sy£'y31 ( a 0-,-J 3S” <br /> ❑ New Construction Use: esidential/Number of bedrooms 3 Code derived design flow rate GPD <br /> GPD <br /> replacement / ❑ Public or co merci -Describe: ---- <br /> Parent material G C /A Ct Al Flood Plain elevation if applicable ft• <br /> General comments �' <br /> and recommendations:C o n1 <br /> Boring# ❑ Boring <br /> $4 Pit Ground surface elev. Depth to limiting factor .57--z in. <br /> Soil Application Rate <br /> Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz <br /> in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. *Eff#1 *Eff#2 <br /> - i J l s i C -Gd <br /> ❑2 Boring# ❑ Boring <br /> v 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/ftz <br /> in./ Munsellll�j Qu.Sz. Cont.Color Gr.Sz.Sh. / *Eff#1 *Eff#2 <br /> _.S /� l G Y a 11 --2- <br /> -7 2- <br /> 6- L <br /> *Effluent#1 =BOD5>30<220 mg/L and TSS>30_<150 mg/L *Effluent#2=BOD5<30 mg/L and TSS<30 mg/L <br /> CST Name(Please Print) Signature CST Number o� <br /> Address ate Evaluation Conducted Telephone Number <br /> t <br /> SBD-8330(R07/00) <br />