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EH 1 74) <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 /> _ p t REPORT ON SOIL BORINGS AND PERCOLATION T TS <br /> LOCATION}LJ ,SectionL,-17rAN, P/g/ colorW,Tovhship orl •^=^�72 <br /> � iGl/�,_ <br /> Lot No. , Block No. County 0[Fil C_oc s.I <br /> ubdivision Name <br /> Owner's Name: ,p ,y <br /> Mailing Address eA.1 e 5' C_ <br /> TYPE OF OCCUPANCY: Residence N No. of Bedrooms :�11 Other <br /> EFFLUENT DISPOSAL SYSTEM: NEW___ / 7 1 ADDITION—REPLACEMENT <br /> �/�•7 <br /> NT <br /> DATES OBSERVATIONS MADE: SOIL BORINGS �_,/9 ' PERCOLATION TESTS �9� <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- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL <br /> BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN <br /> P- <br /> r <br /> P- <br /> P- <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 ! G <br /> B_ <br /> 'r / <br /> a� ,,z. a <br /> PLANVIEW (Locate percolation tests,soilbore holes and suitable soil areas.) <br /> Indicate on the plan the location and square ee of sui able re I dicate nu er o e feet of absorption area <br /> needed for building type and occupancy. Indicate scale <br /> or distances. Give reference point. Indicate slope. eb <br /> Q• <br /> i R <br /> ZEE—I <br /> � 1 <br /> f <br /> } 7 <br /> f <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. <br /> moi/ <br /> Name (print) y �e�r Signature/�� G <br /> Certification No. — 1/ <br /> Name of installer if known <br /> Copy A — Property Owner <br />