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Attach complete site plan on paper not less than 8 112 x I I inches In size. Plan must -00)
Include, but not limited to: vertical and horizontal reference point (BM), direction and Pwoel I.D. ZI ff, A)
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
- Please print all information. F wed by Date
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Personal 1nkx=Uon you provide may be used for secondary puqwpurposed (Privacy Law, 3.15.04 (1) (m)). Aoo 2.1(
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Property Owner PrOP43dy Location
Govt. Lot 55-*
1 4S T a N R C E
Property Ownees Mailing Address Lot # Bkxk # Subd. Name or CSM#
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city $we zip C VNIage Nearest Road
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Now ConstructIon Use: 0 Residential / Number of bedrooms W Code derived design flow rate GPD
0 Replacement 0 Public - "aft:
Parent Material u 7,, rcomnlerdw Fk)od Ptah elevation If appk;aWe
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General cornmerlts
and recominwndatims:
Lj Boring
B(xing # I T/
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Horizon
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Dominant Color
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Redox Description
Qu, Sz. Cont. Color
Texture
Structure
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Roots
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Effluent #1 = BUD > 30 < 220 ffKYL and TSS >30 < 150/�. EMent #2 = t3UU < ju rrKYL WO I bb -3V MgIL
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