HomeMy WebLinkAbout50-24 WiitalaWisconsin Department of Safety ai
Division of industry Services iv|AY IJ o^OZ^Page.I -of_
SOIL EVALUATION REPORT
In accordance with SPS 385, Wis. Adm. Code
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.
Please print all information.
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04(1 )(m)).
Property Ownerier i , .
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Property Owner's Mailing Ad.dress^'^oc'o R^-hl^ L«^-<-Sits Address or CSM and Lot #:^jT^ 00 ^j+k L^/e<^ 7<-cL-
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Flood Plan elevation if applicable_ft.
General comments and recommendations:
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CST Name (PleasePrint) •,, .^» . , V,AKn'r'T^} To ik-^k-i Signature /-: .-CST Number Z2.QQ
Address 'jg0. ge,^ S" 2.2.
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Date Evaluation Conducted,^-r^-_2:->7 Telephone Number7/5" 2.^- ^C^
* Effluent#1 = BOD > 30 & 220 mg/L and TSS > 30 s 150 mg/L * Effluent #2 = BOD, & 30 mg/L and TSS s 30 mg/L SBD-8330(R04/21)
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Redox Description
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Texture Structure
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Soil Application Rate
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Boring #D BoringD Pit Ground surface elev.-ft.Depth to limiting factor.in. / elev._ft.
Horizon Depth
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Redox Description
Qu. Az. Cont. Color
Texture Structure
Gr. Sz. Sh.
Consistence Boundary Roots
Soil Application Rate
GPD/Ft2
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* Effluent #1 = BOD > 30 S 220 mg/L and TSS > 30 s 150 mg/L * Effluent #2 = BOD, £ 30 mg/L and TSS s 30 mg/L
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BAYFIELD COUNTY
CHECKLIST FOR CERTIFIED SOIL TESTS
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Submit the Following (Use Permanent Ink):
0 Check List
El Index Page / Title Sheet (Optional)
El Original Soil Evaluation Report (Submitted in Deed Holders Name - not prospective buyers)
[Zl Original Plot Plan
D Cross Section Soil Profile Sheet (optional)
a Additional Information (Warranty/Quit Claim Deed) (Optional)
Soil Evaluation Report: (Include the following Information)
[3 Parcel Identification Number (must be 23 digit Tax ID#) DO NOT USE 12 digit, they are no longer being used
13 Property Owner's Information (not prospective buyer's name)
0 Property Location (Accurate Legal Description with Sec/Twp/Range)
El Road Name (where driveway is/will be coming off of)
[2 Floodplain Elevation, Flow Rate, Comments and Recommendations
0 Complete Soil Boring / Pit Information
El Date Soil Evaluation was conducted
[3 CST Name, Signature, Number, Address and Phone Number
a *Date Stamp*
Plot Plan: (Include the following information drawn to dimension or to scale)
[71 Bench Mark (Description, Elevation and Location)
0 Contour Lines (Example = 98.0796.0794.0')
13 Pioperty Location (Sec/Twp/Range/, Accurate Legal Description)
E3 Borings (Locations and Elevations)
23 Percent and Direction of Land Slope
0 Well Location (Including Neighboring Wells, if applicable)
[/1 Location of Wetland Areas, Floodplain and Navigable Waters
\Q Buildings, Driveways, and Structures (Location and Descriptions)
2} Location of Property Lines
Ef Existing System Location
[Zf Address Number and Road Name
13 Current Surface Elevation of Wetlands and Navigable Waters
^ CST, Owner and Property Information
North Arrow
Fee:
E.I Certified Soil Tests - Review & Filing Fee . $ 50.00 . . u/forms/sanitary/checklist/checklistforcsts
