Wisconsin



27305000 Wisconsin Department of Safety and Professional ServicesPage of Division of Industry Services67995809575800068275201201420007237095120142000SOIL EVALUATION REPORTIn accordance with SPS 385, Wis. Adm. CodeAttach complete site plan on paper not less than 8 1/2 x 11 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. County Parcel I.D.Please print all information.Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04(1)(m)). Reviewed by DateProperty OwnerProperty LocationGovt. Lot?? STN RE (or) WProperty Owner’s Mailing Address Site Address or CSM and Lot #:CityStateZip CodePhone Number()City Village TownNearest Road236220116205New ConstructionUse:Residential / Number of bedrooms ____________ Code derived design flow rate __GPDReplacementPublic or commercial – Describe: _____________ Flood Plan elevation if applicable ____ft.Parent material _________________________________________ General comments and recommendations:00New ConstructionUse:Residential / Number of bedrooms ____________ Code derived design flow rate __GPDReplacementPublic or commercial – Describe: _____________ Flood Plan elevation if applicable ____ft.Parent material _________________________________________ General comments and recommendations:2171065964565001682750-95313500321310-782320001682750-78232000236220-6858000Boring #BoringPitGround surface elev. ft.Depth to limiting factor in. / elev.______ft.Soil Application RateHorizonDepth In.Dominant Color MunsellRedox Description Qu. Az. Cont. ColorTextureStructure Gr. Sz. Sh.ConsistenceBoundaryRootsGPD/Ft2*Eff#1*Eff#2218376514859000236220-6921500Boring #BoringPitGround surface elev. ft.Depth to limiting factor in. / elev.______ft.380936525298400044951652529840005180965252984000Soil Application RateHorizonDepth In.Dominant Color MunsellRedox Description Qu. Az. Cont. ColorTextureStructure Gr. Sz. Sh.ConsistenceBoundaryRootsGPD/Ft2*Eff#1*Eff#2CST Name (Please Print)SignatureCST NumberAddressDate Evaluation ConductedTelephone Number* Effluent #1 = BOD > 30 ≤ 220 mg/L and TSS > 30 ≤ 150 mg/L* Effluent #2 = BOD, ≤ 30 mg/L and TSS ≤ 30 mg/LSBD-8330 (R04/21)236220-6921500Boring #Page _____ of _____ 21647156159500BoringPitGround surface elev. ft.Depth to limiting factor in. / elev.______ft.Soil Application RateHorizonDepth In.Dominant Color MunsellRedox Description Qu. Az. Cont. ColorTextureStructure Gr. Sz. Sh.ConsistenceBoundaryRootsGPD/Ft2*Eff#1*Eff#2v216471526035000236220-6794500Boring #BoringPitGround surface elev. ft.Depth to limiting factor in. / elev.______ft.Soil Application RateHorizonDepth In.Dominant Color MunsellRedox Description Qu. Az. Cont. ColorTextureStructure Gr. Sz. Sh.ConsistenceBoundaryRootsGPD/Ft2*Eff#1*Eff#2213931525336500236220-6985000Boring #BoringPitGround surface elev. ft.Depth to limiting factor in. / elev.______ft.Soil Application RateHorizonDepth In.Dominant Color MunsellRedox Description Qu. Az. Cont. ColorTextureStructure Gr. Sz. Sh.ConsistenceBoundaryRootsGPD/Ft2*Eff#1*Eff#2* Effluent #1 = BOD > 30 ≤ 220 mg/L and TSS > 30 ≤ 150 mg/L* Effluent #2 = BOD, ≤ 30 mg/L and TSS ≤ 30 mg/L ................
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