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Wis. Dept. of Safety and Professional ServiCJ-N 2 ?
Division of Safety and Buildings- ®~L EVALUATION REPOR I Page of -
'S 11
11 ` STn ~b~iX~ 385, Wis. Adm. Code
Attach c fit MUNi7Y lg V , County
ess than /2 Ir . size. Plan must ZAI
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RRee : ertical and horizontal reference point (BM), direction and
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D.
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Please print all information. Reviewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 1 /,O j
Property Owner Property Location
°p t PC 1.i'^~,c v Govt. Lot j1~ 1/" 114 S T z 3' N R i 5 NI(or)
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
iS 15S 3~a4LS+
City State Zip Code Phone Number ❑ City ❑ Village STown Nearest Road
1.402,1 ( ri IS ) i 3IC)
❑ New Construction Usex Residential / Number of bedrooms _3 Code derived design flow rate `15 o GPD
Replacement ( ❑ Public or commercial - Describe: M, ;A'
Parent material Flood Plain elevation if applicable jU t4 . ft
General comments / (3 - " \ 'IG
and recommendations r n y (a t 4 r
F ri FAILED.
iz- y'
Boring # Boring Sl~-Y Lo9r`~ T-ExTik2E,
F1-1 N ~
pit Ground surface elev. I / ft. Depth to limiting factor i Q in.
e;fE Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 ff#2
r"L -S
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i9 c7 `I(Z y~3 ` r
k v c t 4* Cf y, (p
M - '1 ta'~k `'tl ~ ~R Flo S/S-
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a ZI - 3~ s ~lrz~( ~lrt ~l SI
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Boring # Boring
X Pit Ground surface elev. dC).
ft. Depth to limiting factor Zr-} in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture ESzz. onsistence oundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color = ff#1 ff#2
~ Y,'v1 ~ t,- l' .5 ~ ~ ~ ~ aryl,
-3c. L) ~ era i'yt 4 V i q" 't
' Effluent #1 = BOD 5 > 30:S 220 mg/-L and TSS >30 < 150 mg/L ' Effluent #2 = BOD 5 < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Signature CST Number
Address Date Evaluation Conducted Telephone Number
f 8 r~ A u U- 4 5,-1 S t t s" 6 6 y- S I S `f
1.1 SBD-8330 (R) 1/1 1 1
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Property Owner ~ .6-11A / oa^ V)C' Parcel ID # Page of
❑ Boring # ❑ Boring
Pit Ground surface elev. t=i' Cq ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 ff#2
o a ~
is Z _s S/v r lr~ 1r"~ ~ ; 1 > (o
rj& -q
❑ Boring
❑ Boring #
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft Z
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 ff#2
F] Boring
17 Boring # Ground surface elev. ft. Depth to limiting factor in.
❑ Pit [Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 ff#2
Effluent #1 = BOD , > 30 < 220 mg/L and TSS >30 < 150 mg/L ` Effluent #2 = BOD , < 30 mg/L and TSS < 30 mg/L
The Dept. ol"Safety and Professional Services is an equal opportunity service provider and employer. It'you need assistance to
access services or need material in an alternate format. contact the department at 608-266-3151 or TTY through Relay.
SB1)-s;3, (R I I I I)
Soil and Site Evaluation Site Plan page 3 of 3
94
SE'/4,NE'/4,S27T28N/R15 W
Cady township
St. Croix county l~~ 100,
y t retta Larrabee o o
CSTM 224580 3/
l3
LEGEND a~~~ unknown
Kcal of well
A: 102.3' bottom
r
X - back hoe pits 5
a - grade elevation a~
r
- trees
contour 1 i t Q~'~ 1
No SPS 383 set back
problems sue! t 9q-Z'
Scale 1" - 30'
except where indicated
J'\
Part of 4.75 A.C.
Lot lines pointed
out by owner
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