HomeMy WebLinkAbout032-2174-15-000 (3) RECEIVED
DEC 1 8 2003
Wisconsin Department of Comme
ST.CROIX CoUNIL = ALUATION REPORT Page ) of
Division of Safety and Buildings
..r+r!r.!..;.t1 AL.. ..,n 1, :.,Wis. Adm. Code /�/
County �S�f;/
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size.Plan must
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include,but not limited to:vertical and horizontal reference point(BM),direction and parcel I.D.
percent slope,scale or dimensions,north arrow,and location and distance to nearest road. 0301 —01.11y- /5"-e3G )
Please print all information. R ewe Date
Personal information you provide may be used for secondary purposes(Privacy Law.s.15.04(1)(m)). I �//12(4 y
Property Owner ,7 Property Location
�)L, .�! //-5 Govt.Lot�` 1/40- 1/4 9 7 T 3) N R/9/ (or&
Property Owner's Addree Lot s#✓ Block Subd.N or CSM# / /
1' /_f? Aj4211✓.- /,.J AJ .i.Li=.0 1K .r9/a'/t''
City State Zip Code Phone Number ❑City�—❑Village 0 Town Nearest Road
S.trir s, I I{l fi I S j�?5"1 ( ) Qn„ <>,=. I ,T7
CA New Construction Use:a Residential/Number of bedrooms .3 ' Code derived design flow rate j ' _Zee GPD 1
❑Replacement ❑ Public or commercial-Describe: __ _
Parent material Flood Plain elevation if applicable -/Y/ ft.
General corm,ents /..� ,e/, 9o, ,
and recommendations: �F
Boring#
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❑ Pit Ground surface elev. 2g, ft. Depth to limiting factor G., in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fW
in. Munsefl Qu.Sz. Cont.Color Gr.Sz.Sh. •Eff#1 *Eff#2
1
3 I AI X1111I MEIR IFIM/
1, 11MER!IIMIll s41.:W rillillEMENI — MEM
.PIMPIII III ;! . 111 -
Boring# ❑ Boring //
®Pit Ground surface elev. 9,,i ft. Depth to limiting factor //) in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft
/ in. Munselll// Qu.Sz. Cont.Color - Gr.Sz.Sh. _//n� q •Eff#1 'Eff#2
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s— / fit A--ae.P/l ; _<-e - ', .5,-/ r, .,(:- _ - . 6 , .
•Effluent#1=BOD5>30<220 mg/L and TSS>30<150 mg/1_ •Effluent#2=BODS<30 mg/L and TSS<30 mg/L
CST Name
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Address G--- Date Evaluation Conducted Telephone Number
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Property Owner Parcel ID# Page of
# ❑ Boring
3 Boring j, pit Ground surface elev. ft. Depth to limiting factor S-1/ in.
Soil • ication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. •Eff#1 •Eff#2
1111111- IMMIRSIIIM111111
IF/ale l I_._ 11 N' O WM : x !!41! - NM=
111111b01171 INIM cM -
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/ft
in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. •Eff#1 •Eff#2
# ❑ 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/ff
in. Munsell Qu.Sz. Cont Color Gr.Sz.Sh. •Eff#1 •Eff#2
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•Effluent#1=BOD5>30<220 mg/L and TSS>30<150 mglL •Effluent#2=BODD<30 mg/L and TSS<30 mg/1.
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S8D4330(8.6/00)
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