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t0 <br /> DEPARTMENT OF HEALTH AND SOCIAL SERVICES,DIVISION OF HEALTH <br /> (Pursuant to H 65.06.Wisconsin Administrative Code) <br /> NAME OF SUBDIVISION C S",yy? <br /> CITY <br /> VILLAGE Dp 'r� <br /> LOCATION OF SUBDIVISION: TOWN X OF CKSPN COUNTY P(I/ fff SECTION OWN -0 N: RANGE L-W <br /> ((.Check'O'In.l <br /> aV <br /> NAME OF OWNER J ' 0 <br /> ADDRESS 26.5LmEldhdfWi6ile•- WIC, Sf 89? <br /> (Numtlu b Saon (Plec.) Is caret (Zip Coati <br /> NAME OF SUBDIVIDER <br /> ADDRESS <br /> INumo.T 6 Saeed (Piet.( 15tau1 (Zip Cotl.) <br /> SUBOI VISION WATER SUPPLY FROM: PUBLIC WATER SUPPLY �j PRIVAT WELLS <br /> SUSOIVISION OATA: AREA IN ACRES—%- p <br /> o1 NUMBER OF LOTS s - MINIMUM LOT AREA,S UARE FEET <br /> DISTANCE TO NEAREST NAVIGABLE SURFACE WATER Ad�6ClCht FEET. (IF (THIN%MILE) <br /> NAME OF LAKE OR STREAM RAA LAAfe. <br /> DATES OBSERVATIONS MAKE: SOIL BORINGS8/'?d J9S PERCOLATION TESTS <br /> SOIL BORING TESTS <br /> TIST TOIAIOa•T» oa••»ro wou»o v..raR :NCNu GNARAC7rfX00CACNau.<4AraA.a TN TNrcanul..:»CNas <br /> V"!..lA :NCNfS p.1[MvIO EST:..Arao N.G.w <br /> >{! o Q" 8ns� S"-61" Be fist,-IthedStA <br /> P la <br /> a- z 70 >�d 0-7 'ail ► 7 "--70" <br /> e- <br /> a <br /> e- <br /> s- I <br /> a <br /> _ I <br /> e- <br /> e- <br /> a- <br /> e- <br /> a- <br /> a- <br /> a- <br /> e- <br /> a- I <br /> a- <br /> a- <br /> a- <br /> a- <br /> a- <br /> a- <br /> a- <br /> a I <br /> .NOTE: IP-SPACE IS INAOEOUATE TO REPORT AL1.3011.BORINGS. USE ADDITIONAL PORMS. 9VBR <br /> fiEm <br />