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Wisconsin Department of Commerce C?"/
Wisconsin EVALUATION REPna ~
Division of Safety and Buildings (j i Page ~ of
in a Arcaan0 9vv44m 85, Wis, Adm. Code 4FRM4T7VZYW 12
Attach complete site plan on a er 5T. CFZ County
p p 6DI~yy} jt;t&s in size. Plan must
include, but not limited to: vertical and h rizon~ef rb direction and
percent slope, scale or dimensions, north arrow, and location and dunce to nearest road, Parcel I.D. Y.,~ •1
Please print all information. Revie d by ate
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner ! 3
1 ( Property Location
Govt. Lot ,t 1/4 L~1/4 S ~j- T•~~' N R E O r w)
Property Owners Mailing Address
Lot # Block # Subd. Name or CSM#
City State Zip Code Phone Number
❑ City ❑ Village -0 own Nearest Road
l y tL, 173'
New Construction Use: Residential /Number of bedrooms Code derived design flow rate
❑ Replacement ❑ Public or commercial - Describe: GFD
Parent material U F 5 4 c ; ~)l~j' Flood Plain elevation if applicable ft.
General comments
r
and recommendations: 7,z f
'c-ko,
' Boring
Boring
L~ pit Ground surface elev. 4 6 , ft. Depth to limiting factor % in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots D/fP
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
Y t- t C~YIti~ z
.S ;
c~
Boring Boring ,
L` II Pit Ground surface elev. Depth to limiting factor C in.
JOii t1 'iititii.Jn .`w°ao
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
1G~12- C slrl = t~
L' s v
Effluent #1 = SOD > 30:5 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = B0D < 30 mpL and TSS < 30 m pt
CST Name (Please P 'nt) Signature/ CST Number
Address~ DateEvalu-nGonducted ~Telephone Number
Property Owner t i~ F l ~ti°1 I`~ Parcel ID # / Page of
❑ Boring
Boring # f +
`dam Cj-pit Ground surface elev. 6 c ft. Depth to limiting factor In. SOU Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence -Boundary Roots GPp/fP
In. Munsell Qu. Sz. Cont. Color Gr..Sz. Sh. 'Eff#1 "Eff#2.
> , z.{ b ,c
A t,
(6 C,
,
❑ Boring
F 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
I in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1. "Eff#2
t
I
I
Boring
F-1 Boring # Ground surface elev. ft. Depth to limiting factor in.
❑ Pit Soll A Ilcatiort Rate.
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP /ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#Z
I
j
j_
I
` Effluent #1 = BODE > 30 5 220 mg/L and TSS >30:_< 150 mg/L ' Effluent #2 = BQDb-_< 30 mg/L and TSS < $0 mg/L
I'he Department of Commerce is an equal opportunity service provider and employer. If you need' assistance to access services or
need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777;
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