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EH 115
<br /> WISCONSIN DEPARTMENT OF HEASTN AND SOCIAL SERVICES
<br /> DIVISION OF HEALTH,BUREAU OF ENVIRONMENTAL HEALTH
<br /> • P.O. BOX 309
<br /> • MADISON,WISCONSIN 53701
<br /> REPORT ON SOIL BORINGS AND PERCOLATION" '/4TESTqS,
<br /> LOCATION: , -51/404,Section f,T N, RAI E (or) W,Township or Municipality / ,1 ' .e /\
<br /> Lot No. , Block No. County 43 LC N442 ` 1
<br /> / { r Subdivision Name
<br /> Owner's Name: 4,e, R.t. r 14 1/,.r
<br /> Mailing Address: L,u•+e 6•s /'rr - LU(SC —
<br /> TYPE OF OCCUPANCY: Residence X No. of Bedrooms I Other
<br /> EFFLUENT DISPOSAL SYSTEM: NEW X ADDITION' REPLACEMENT
<br /> DATES OBSERVATIONS MADE: SOIL BORINGS �/c /7 7, PERCOLATION TESTS -7p. f`�-7 7
<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—, ,3 `'
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<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 /> et-
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<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 ares Indicate number ofuare feet of absorption area
<br /> needed for building type and occupancy. .,) C) F1 N'f''' -e Indicate scale
<br /> or distances. Give horizontal and vertical reference points. Indicate slope.
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<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. — j/
<br /> Name (print) �� �'t r�I Ck K.�� , i n `�� G Certification No. �f
<br /> Address tip `e L. S /`j ` --- i S < 6----y f
<br /> Name of installer if known (��`1 ��
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<br /> CST Signature gae 'AA-LA.
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<br /> COPY A—LOCAL AUTHORITY l
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