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EH 1:1-5 <br /> WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH <br /> P.O. BOX 309 <br /> MADISON,WISCONSIN 53701 <br /> /�� PORT ON SOIL BORINGS AND PERCOLATION TEST p <br /> LOCATION:/1�11L'/a, /n, Section �/T55N, Ra-E{ W,Township or Municipality ,t <br /> Lot No. , Block No. ` County Ag&rX dt <br /> Subdivision Name <br /> Owner's Name: //��u <br /> Mailing Address: �� x[ )?" Ve <br /> TYPE OF OCCUPANCY: Residence No.of Bedrooms Other <br /> EFFLUENT DISPOSAL SYSTEM: NEW ADDIT ON REPLACEMENT <br /> DATES OBSERVATIONS MADE: SOIL BORINGS S PERCOLATION TESTS <br /> SOIL MAP SHEET SOIL TYPE <br /> PERCOLATION TESTS <br /> TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL,INCHES RATE <br /> NUM- SINCE HOLE HOLE AFTER INTERVAL <br /> INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN <br /> BER <br /> P-/ �4 wee /ire5f /O /� �� y <br /> P- /S'` <br /> SOIL BORING TESTS <br /> TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES <br /> NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) <br /> B- Z X4 w®n 7�Q �� �` Ts . Zo",O x, Imsti oi( It. Fa X41, <br /> B- y 7� <br /> .410 4 1 �( �,s �3,�Fae 5a gr, / e <br /> PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) <br /> Indicate on the plan the location and square feet of suitable areas y Indicate number of square feet of absorption area <br /> s <br /> needed for building type and occupancy. ` : " Indicate scale <br /> or distances. Give horizontal and vertical reference points. Indicate slope. <br /> 8 cL <br /> I <br /> e <br /> I 5� � P► � <br /> qL <br /> �' k t �;R !zy t N <br /> ri 1C <br /> i <br /> +—+ li, UAt <br /> - -- <br /> e n -I <br /> e 1 <br /> I,the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures <br /> and methods specified in the Wisconsin Administrative Code,and that the data recorded and location of test holes are correct <br /> to the best of my knowledge and belief. Q/ <br /> Name (print) 0alLe n �e/ti50 h Certification No. �� �51v <br /> ,]dress ;R4`• a` W e 16 <br /> -ie of installer if known <br /> LOCAL AUTHORITY CST Signature���� <br />