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Wisconsin Department of Safety and Professional Services
Division of Industry Services Page /-of_
SOIL EVALUATION REPORT
In accordance with SPS 385, Wis. Adm. Code | county
Attach complete site plan on paper not less than 81/2x11 inches in size. Plan must include,
but not limited to; vertical and horizontal reference point (BM), direction and percent slope,
scale or dimensions, north arrow, and location and distance to nearest road. /„/..„ .,, ,„(t!
Please print all information, t i^-'^-'/y'^f'^'fe^-^-^.Personal information you provide may be u^edforjse^ondagLpurpos^s (Privacy Law, s. 15.04(1)(tfi)).
Property Owner ^^e-t^jf^t 0>t-/~c /^S'Vf^ | Property Location
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greperty Owner's Mailing Address
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k Effluent #1 = BOD > 30 s 220 mg/L and TSS > 30 £ 150 mg/L • Effluent #2 = BOD, £ 30 mg/L and TSS s 30 mg/L SBD-8330 (R04/2
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• Effluent #1 = BOD > 30 d 220 mg/L and TSS > 30 s 150 mg/L * Effluent #2 = BOD, ss 30 mg/L and TSS S 30 mg/L
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^a-nnn^ ....... .-BAYF!ELD-90UNTL.. —_- ID u-i^'.M^ 7-] CHECKLIST FOR CERTIFIED SOIL TESTS ^ [!!!
;!lj APR ?6?'!//'! W
Submit the Following (Use Permanent Ink):
a Check List ^.
D Index Page / Title Sheet (Optional)
D Original Soil Evaluation Report (Submitted in Deed Holders Name - not prospective buyers)
D Original Plot Plan
D Cross Section Soil Profile Sheet (optional)
D Additional Information (Warranty/Quit Claim Deed) (Optional)'
Soil Evaluation Report: (Include the following Information)
ETParcel Identification Number (must be 23 digit Tax ID#) DO NOT USE 12 digit, they are no longer being used
BTroperty Owner's Information (not prospective buyer's name)
E"Property Location (Accurate Legal Description with Sec/Twp/Range)
ETRoad Name (where driveway is/will be coming off of)
DTIoodplain Elevation, Flow Rate, Comments and Recommendations
ETComplete Soil Boring / Pit Information
SDate Soil Evaluation was conducted
ETCST Name, Signature, Number, Address and Phone Number
D *Date Stamp*
Plot Plan: (Include the following information drawn to dimension or to scale)
EfBench Mark (Description, Elevation and Location)
B-Contour Lines (Example = 98.0' ,96.0' ,94.0')
BT'roperty Location (Sec/Twp/Range/, Accurate Legal Description)
Q^Bbrings (Locations and Elevations)
[TPercent and Direction of Land Slope
Q^/Vell Location (Including Neighboring Wells, if applicable)
Q-1jxation of Wetland Areas, Floodplain and Navigable Waters
B^Buildings, Driveways, and Structures (Location and Descriptions)
'Location of Property Lines
'Existing System Location
B^Address Number and Road Name
ET Current Surface Elevation of Wetlands and Navigable Waters
S^CST, Owner and Property Information
EfNorth Arrow
Fee:
Soil Tests - Review & Filing Fee $ 50.00 U/forms/sanitary/checklist/checklistforcsts