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ESI 115 <br /> WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> DIVISION OF HEALTH, BUREAU OP ENVIRONMENTAL HEALTH <br /> P.O. BOX 309 <br /> MADISON,WISCONSIN 53701 <br /> REPORT ON SOIL BORINGS AND PERCOLATION TESTS�+ <br /> LOCATION: k'14,SEva, Section SU, T1fN, R 4 0(or) W, Township or Municipality `-� ' � <br /> Lot No. --_, Block No. County q r rl r7f <br /> r � Subdivision Name <br /> Owner's Name: <br /> Mailing Address: sC S f`' N L.V l 3C• 7 <br /> TYPE OF OCCUPANCY: Residence _ No. of Bedrooms Other <br /> EFFLUENT DISPOSAL SYSTEM: NEW 'C ADDITION REPLACEMENT <br /> DATES OBSERVATIONS MADE: SOILBORINGS PERCOLATION TESTS <br /> SOIL MAP SHEET SOI L TYPE <br /> PERCOLATION TESTS <br /> TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE <br /> NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL <br /> BER <br /> 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN <br /> 7T 9- <br /> P � ave 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- 1 ,7a If 65 'f ec "6,4 ,( C okrxt Sail ,w, N, <br /> B / 3\ 6;1 Sz� : tiroN 501) ✓ �JFL <br /> ,r <br /> B- <br /> ,r �7C - (� 3 ., Ts II 'Snnts( crcv L <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 arras Inc�ate number of sq ref t of absorption area <br /> needed for building type and occupancy. N FT �L Y FQ Indicate scale <br /> or distances. Give horizontal and vertical reference points. Indicate slope. <br /> C • <br /> or <br /> f1 AOct <br /> til Q 4 - — <br /> i T <br /> 7 <br /> tN <br /> 3 O <br /> Cl 71 <br /> � e i <br /> I <br /> r d <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 kn led a and belief. <br /> Name (print) v 1 � + < < e Certification No. / <br /> Address Vli r J S c , <br /> Name of installer if known Ifni <br /> CST Signature <br /> COPY A— LOCAL AUTHORITY <br />