MIDLAND HEALTH and
   SENIOR SERVICES

OSSF SOIL EVALUATION FORM

OWNER'S NAME________________________________________________________________________________________

PHYSICAL ADDRESS____________________________________________________________________________________

NAME OF SITE EVALUATOR____________________________________  REGISTRATION NUMBER_____________________

DATE PERFORMED_______________________________  PROPOSED EXCAVATION DEPTH___________________________

• At least two soil evaluations must be performed on the site, at opposite ends of the proposed disposal area.   Please show the results of each soil evaluation on a separate table.   Locations of soil evaluations must be shown on the site drawing.

• For subsurface disposal, soil evaluations must be performed to a depth of at least 2 ft. below the proposed excavation depth.  For surface disposal, the surface horizon must be evaluated.

• Please describe each soil horizon and identify any restrictive features in the space provided below.  Draw line at the appropriate depths.

I certify that the above statements are true and are based on my own field observations.

_________________________________                          _______________________________
     (Signature of Site Evaluator)                                               (Phone Number)

Features of Site Area