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Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of 3
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County
Attach complete site plan on paper not less than 812 x 11 inches in size. Plan must C rv I
include, but not limited to: vertical and horizontal reference point (BM), direction and parcel I.D. p
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please print all i fo Re by Date
Personal information you provide may be used for ndary Purposes ~rr~ laN. s.1 04 (1) (m)). (0 (f
3
Property Owner Location
Qbn .JUN 1 0 2002 Go . Lot N Vj 1/4 N~1 114 S Cf T 2-q N R t-7 E (o
Property Owner's Mailing Address-, , ST
C OI C tjNTY # Block # S~t~d. Name or CSM#
ZON~
City l State Zip Code Phone Number City _ ❑ Villagell ~t Town Nearest Road
1 l~ (l5 )7t~0 ~ 12(o I-tv
%Aew Construction Use esidential / Number of bedrooms Code derived design flow rate 4,'30 4, QQ GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent material / Flood Plain elevation if a licable ft.
General comments Sys Pl~►'t e k v /G0. /0 Ikal" 9 Ile Wi~ Gthl~~ra
and recommendations: e (,e 9 Bonn9 # ❑ Boring
pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 *01#2
ov e-- C-3
(r2 ( Si L( Z ~ C -
Z SCI' Z: r ~S ~ . y
4 a-6- LP- 141
nno ? ~ ?
F2-1 Boring # pit Ing
Ground surface elev. aR QN6 ft. Depth to limiting factor G in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 "Eff#2
I1 77
Z J6Z7 (0\4f - ( C3 ,
7-~D 1 C30. cD 5cl
,-3 TFIF
m
Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 150 mg/L ' Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L
CS Name (Please Print) Signature CST Number
cr - 25 9
Address Date Evaluation Conducted Telephone Number
' p
Properly Owner Parcel ID # G Br / / page ~ of
e `
5 Boring # ❑ Ing
pit Ground surface elev. -1' l • ft. Depth to limiting factor JQ in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDt t2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2
I -(1 Z ~Sl) r r.~r. c I~ S
❑ Boring # ❑ Boring
❑ pit Grr.und surface elev. ft. Depth to limiting factor in. c~j Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDtW
. Sz. Cont. Color Gr. Sz. Sh. Eff#1 Eff#2
In. Mansell Qu
Boring # ❑ Boring
Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. •Eff#1 •Eff#2
Effluent #1 = BODS > 30 < 220 mg/- and TSS >30 < 150 mg& ' Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/l.
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an altemate format, please contact the department at 608-266-3151 or TTY 608-264-8777.
SBD-8330 (807100)
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PAGE 3 OF -3
NAME O r~ e LOT# LEGAL DESCRIPTION Nw X IJw 14 ,S 12-1 ,N,R, /
SCALE: I"=
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BM 1 ELEVATION, C~
BM 1 DESCRIPTION 4o,, 4 1 "OLtc-
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BM 2 ELEVATION 111 / U
S cc. Q
BM 2 DESCRIPTION d rr V~-- -e
SYSTEM ELEVATION 160,
SYSTEM TYPE (V1 G U rvd S y S e w~
CONTOUR ELEVATION 9q ZD
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91
0
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SIGNATURE DATE -
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