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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS <br /> INDUSTRY, , , DIVISION <br /> LABOR AND PERCOLATION TESTS 1115) MADISON, O 7969 <br /> HUMAN RELATIONS C / <br /> ' (H63.090) & Chapter 145.0451 <br /> LOCATION' TION: TOWNSHIP/MUNICIPALITY: OT NO.'.BLK.NO.: SUBDIVISION NAME: <br /> NF Y, Y" i W <br /> /T37 N/R ISE P /1 A cl f�_ L jAA ka <br /> C LINTY: OW R'S BUYER'S"AMC: MAILING ADOR : <br /> Of Nt l�� a LR /V177U1_ l/// K2 <br /> USE - DATES OBSERVATIONS MADE <br /> Residence II BEEFMS: COMMERCIALO S RI PTION: E�New ❑Replace I R,LE/- CRPT NSPE A ION TESTS. <br /> RATING:S-She suitable for system U-Sita am nimble far rysam K` <br /> CONVENTIONAL', MOUND IN-GROUNDPRE55URE: SVSTEM�INFI LL HOLDING TANK: RECOMMENDED SYSTEM: <br /> ❑S [�lU ❑S L IU ❑S 3 ❑S NU ®S ❑U <br /> If Percolation Tests are NOT required DESIGN RATE: II any gonion of the tested area is in the <br /> oder e.1163.0915111)),indica �/�, Floodplain,indicate Floodplain elevation <br /> -' - --- � - -PROFILE DESCRIPTIONS DESCRIPTIONS <br /> BORING TOTAL PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH <br /> NUMBER DEPTH IN, ELEVATION OBSERVED EST.HIGHE TO BEDROCK IF OBSERVED SEE ABBRV,ON BACK.) <br /> Or j <br /> lie, <br /> '/iN�5G <br /> e r `fir' AI. ..73%_ ,i" I i-j Or <br /> hroN� <br /> B-S' yN i✓aNe, 3„er / BN ._l HSN;[- / A) b i <br /> B- <br /> PERCOLATION TESTS <br /> TEST DEPTH WATER IN HOLE TEST TIME CHOP IN WATER LEVEL INCHES RATE MINUTES <br /> NUMBER INCHES AFTERSWELLING INTER VALMIN. p RI Dt P RIDD P PERINCH <br /> P. <br /> P- <br /> P- _ <br /> PLOT PLAN: Show IOcmlom Of percolation tests, soil borings and the dimensions Of suitable soil areas. Indicate stale or distances. Describe what are the hori <br /> tonal and vertical elevation reference points and show their location on the plotplan. Show the surface elevation at all borings and the direction and percent <br /> of land time. <br /> SYSTEM ELEVATION N A °✓AGl a <br /> 7��o Niel <br /> p ev_ioo -7GP or_P-fnST” <br /> Cl <br /> I <br /> I "�`'OI��` � � � • iN <br /> I <br /> �_.,� <br /> i J <br /> Qhe untlersig.rd,hereby certify that the .it tests reported on this form were made by me in accord with the procedures antl methods specified in the Wi nommin <br /> Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge antl belief. <br /> NAME(print): TESTS WERE COMPLETED ON: <br /> ADDRESS: <br /> CERTIFICATION NUMBER: PHONE NUMBERIoptlpMD: <br /> " CST SIGNATU{t <br /> DISTRIBUTION: Original and one copy t0 Local Authority,Property Owner and Soil Tever. <br /> DILHR SBD�63 R.02/92) -OVER- '--- �✓ d <br />