HomeMy WebLinkAbout032-2193-11-060oaq
Wis. Dept of Saf�y and Pro ent EVALUATION REPORT page Of
omsion of Safety 4nd Boe 3
CO inacconianwwMSPS385,wis. Adm. Code county
Attach corroete sfte plan on paper not less than 8 112 x 11 WOm In size. Plan must
Include, but not limited to: verticed and hortvnW reference point (BM), direction and Parcel I.D. �7\
percent slope, scale or dimensions, north arrow, and locatJon and distance to nearest road. I uz - Z U
Please print all Informadort. Reviewed by Date
PemmW Information you pmvWe may be used for second" puqvxm (Pffvacy Law. s. 16.04 (1) (m)).
Property Property Location
Govt. Lot L I JlU'L 114 S T N R E (or) W
A
Property Owner's Maftg Address Lot Block # Subd.." or CSW
3
7"-
City , State Zip Code Ph" Nmtw 0 city 0 Vdiap CaTown Nearest Road
FNew Construction Use: Residential / Nurnber of bedrooms Code derived design flow rate, GPD
100 Repkwcement Public or comnwdal - Describe:
Parent material r Flood Pkdn elevation If appk2ble
General convnents
and reconvnendations:
Bonin # ..a [:] Boring
a
F7 18odno # 0 BoritV
Horizon Depth
I in.
Pit Ground
surface elev.
Depth
to urnjung
factor
in.
Um Rate
Soo fio, , Rate
Dominant Color
Redox Description
Texture
Stnicture
sistence
Roots
G
GPD/ft
IP
ff
Munsell
Qu. Sz. cont. c0ior
Gr. Sz. Sh.
0.11�
0or"
0
Effluent #1 = 1300 > 30 < no ffq& and TSS >30 :5 150 ffV&
S
CST Na 01aso t Sign atu
Address
Effluent #2 =1300 5 < 30 ffjqfL aW I bb <.5U Mg/L
M Number
Wts Evaluation Conducted Telephone Number
SB"330 (RI 1/11)
"IL
Property Owner ,:,,` .C. ''..-a.. ..,„
Parcel ID #
40
Borft # ft. Depth to lim" factor
Pit Ground surface elev. In.
Page of
Z-
will
Bocing # Bo"
11 pit Ground surface elev. ft. Depth to UmiMg factor In. I S61 POMication Rate I
Redox Description
Qu. Sz. Cont. Color
Stucture
Gr- Sz. Sh.
UM
Boring # Q Bming
I Ground surface elev. -ft. Depth to limiting factor in.
CZ^H Artrd"t"n Onfeb
Depth
In.
Redox Descript:ion
Qu. Sz. Cont, Color
SWcture
Gr. Sz. Sh.
* Effluent #1 = BOD 6 > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD 6:5 30 mgtL and TSS < 30 mg/L
The Dept. of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to
access services or need material in an alternate format, contact the department at 608-266-3151 or TTY through Relay,
SOD-8330 (RI 1111)
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