HomeMy WebLinkAbout48-24Wisconsin Department of Safety & Professional Services
Division of Industry Services
ORIGINAL
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)).
County ^^/^^
Parcel I.D.7^'jr^.^ ^y^y
Reviewed by
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Property Owner
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Property Location
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Site Address or CSM and Lot #: ^ -SW J" S^A ^r~ &cl > D^ •
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D City D Village
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Q New Construction Use: B'Residential/Numberofbedrooms Y
0 Replacement D Public or commercial - Describe:
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CST Name (Please print)/?7<^^ f^u^Signatuiu;^^&^CST Number /^a Yc^^o
Address // 3 tt0 ^o^e^ Ct.^ A<,
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Date Evaluation Conducted7//^/^s,Telephone Number7<5T-<^/~//^
' Effluent #1 = BOD > 30 S 220 mg/L and TSS > 30 S 150 mg/L * Effluent #2 = BOD, & 30 mg/L and TSS & 30 mg/L
SBD-8330 (R03/22)
#48-24
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Redox Description
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Texture Structure
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Conslstence Boundary Roots
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Boring #D Boring
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Redox Dsscription
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' 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
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S'R-00^0
^ ^ BAYFIELD COUNTY
CHECKLIST FOR CERTIFIED SOIL TESTS ]| ,j|
APR ?€'i^!^ 1";
Submit the Following (Use Permanent Ink):
D Check List
D Index Page / Title Sheet (Optional)
D Original Soil Evaluation Report (Submitted in Deed Holders Name - not prospective buyers)
a 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)
&1:>arcel Identification Number (must be 23 digit Tax ID#) DO NOT USE 12 digit, they are no longer being used
C3"Property Owner's Information (not prospective buyer's name)
B^roperty Location (Accurate Legal Description with Sec/Twp/Range)
B^Road Name (where driveway is/will be coming off of)
D Floodplain Elevation, Flow Rate, Comments and Recommendations
S^omplete Soil Boring / Pit Information
B^ate Soil Evaluation was conducted
B<ST Name, Signature, Number, Address and Phone Number
D *Date Stamp*
Plot Plan: (Include the following information drawn to dimension or to scale)
B^ench Mark (Description, Elevation and Location)
B-'Contour Lines (Example = 98.0'/96.0794.0')
B^roperty Location (Sec/Twp/Range/, Accurate Legal Description)
Sorings (Locations and Elevations)
B^Percent and Direction of Land Slope
B^A/ell Location (Including Neighboring Wells, if applicable)
0<ocation of Wetland Areas, Floodplain and Navigable Waters
B^uildings, Driveways, and Structures (Location and Descriptions)
B^Location of Property Lines
(isting System Location
EfAddress Number and Road Name
B'Current Surface Elevation of Wetlands and Navigable Waters
[EfCST, Owner and Property Information
Ef North Arrow
Fee:
D Certified Soil Tests - Review & Filing Fee $ 50.00 U/forms/sanitary/checklist/checklistforcsts