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Wisconsin Department of Safety and Professional Services
Division of Industry Services
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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, f ^^) -^^
Personal information you provide may be u^ed forj3epondaQLpurpos$s (Privacy Law, s. 15.04(1)(
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Date Evaluation Conducted
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' Effluent #1 = BOD > 30 s 220 mg/L and TSS > 30 £ 150 mg/L ' Effluent #2 = BOD, s 30 mg/L and TSS s 30 mg/L
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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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.n r,f\^i BAYFIELD COUNTY)i<- <JV< n CHECKLIST FOR CERTIFIED SOIL TESTS Ir
APR ?6^!/7i
Submit the Following (Use Permanent Ink):
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a Check List 7/%Y
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)
a Additional Information (Warranty/Quit Claim Deed) (Optional) ~
Soil Evaluation Report: (Include the following Information)
BTarcel Identification Number (must be 21diait Tax ID#) DO NOT USE 12 digit, they are no longer being used
QTroperty Owner's Information (not prospective buyer's name)
B"Property Location (Accurate Legal Description with Sec/Twp/Range)
ETRoad Name (where driveway is/will be coming off of)
ETTIoodplain Elevation, Flow Rate, Comments and Recommendations
ETComplete Soil Boring / Pit Information
BDate Soil Evaluation was conducted
Br'CS'T Name, Signature, Number, Address and Phone Number
D *Date Stamp*
Plot Plan: (Include the following information drawn to dimension or to scale)
ETBench Mark (Description, Elevation and Location)
B-Contour Lines (Example = 98.0'/96.0'/94.0')
ETProperty Location (Sec/Twp/Range/, Accurate Legal Description) . -
Q^orings (Locations and Elevations)
B^ercent and Direction of Land Slope
B^/Vell Location (Including Neighboring Wells, if applicable)
Q-ljxation of Wetland Areas, Floodplain and Navigable Waters
B'Buildings, Driveways, and Structures (Location and Descriptions)
'Location of Property Lines
System Location
EkAcidress Number and Road Name
Ef Current Surface Elevation of Wetlands and Navigable Waters
ETCST, Owner and Property Information
ETNorth Arrow
Fee:
B^ertified Soil Tests - Review & Filing Fee $ 50.00 U/forms/sanitar//checklist/checklistforcsts