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Name of Owner � / // - //�r -/` Count y ' Permit No. <br /> PERCOLATION TESTS^— <br /> I, the undersigned, hereby certify that the Percolation Tests reported on this form were made by me or under my supervision <br /> in accord with the procedures and method specified in Section H 62.20 (3), Wisconsin Administrative Code, and that the data <br /> recorded and rati of test holes are correct to the best of m knowla e a/r�tl lAiej� <br /> NAME � � TITLE — / 'Q40- It -` <br /> REGISTRATION NO. (Type or Printfor MASTER PLUMBER LICENSE No. <br /> ADDRESS <br /> DATE OF TEST ) SIGNATURE <br /> .. - _ <br /> - - --. - ----------------- <br /> -l <br /> MASTER PLUMBER MAKING APPLICATION MP <br />` Signature: / it 2 �.`.. License Number: MP RSO/ m v <br /> For: Provide sketch below of system <br /> (employer) (Include direction and percent of slope and all applicable distances) <br /> -i i� <br /> 20' - <br /> &.Soil Bore.Holes) <br /> � - <br /> -15' •r- N _ _LU. <br /> -10 <br /> -5�� Y-�. <br /> i. <br /> — <br /> - <br /> -_G.-__---= -- -,� -. - i .fII-- -- <br /> 7 <br /> --5 <br /> -20 -PRO FILE- (Indcae.Groundwater <br /> --orb_-e..dr <br /> .o._c_k�_w_�1�=—pL- <br /> b�le�) <br /> =2 <br /> - <br /> _ <br /> - _ <br /> -4;-- <br /> D 7-1-]Ato <br /> -111 ---- -- --- - - -L1 I I LH <br /> - <br /> Note: The application cannot be considered for filing until all of the above questions are answered and the fee paid. <br /> --________-_____---_-_---_____--------------------___.-_______.._---_--_______--____-____....___-___-____-___.__._____-.----___.---__-_--_-._----__ <br /> Do not write in space below- FOR DEPARTMENT USE ONLY <br /> Date of Application Fees Paid State County <br /> Permit Issued/Rejected (date) Inspection Yes No <br /> Issuing Agent Name Valid No. Date Rei d <br /> i <br /> DIVISION OF HEALTH,P.O.BOX 309,MADISON,W1.53701 —Revised 4403 <br />