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NAMES <br /> COUNTYs <br /> SEPTIC TANK PERMIT NUMBERS <br /> REPORT ON SOIL PERCOLATION TEST <br /> AND SOIL BORINGS <br /> TO <br /> DIVISION OF HEALTH —PLUMBING SECTION <br /> P.O,BOX 309, Madison, Wig, 53701 <br /> Pursuant to H 62,20, Wig. Administravive Code <br /> P E R C O L A T I O N T E S T <br /> TEST DEPTH CHARACTER OF SOIL HOURS WATER TEST TIME DROP IN WATER LEVEL INCHES MINUTES <br /> NUMBER INCHES THICKNESS IN INCHES SINCE HOLE IN HOLE INTERVAL SECOND TO EXT TO LAST TO FALL <br /> let WETTED OVERNIGHT IN MINUTES LAST PERIOD LAST PERIOD PERIOD ONE INCH <br /> EXAMPLE <br /> P - 0 3611 TOP SOIL 1D"' CLA 26115 YES OR NO 30 60 <br /> IL 71 <br /> 2020 el r <br /> RECORD DATA FROM !W11 NUM OF 3 TEST HOLES <br /> COMPUTE SIZE OF ABSORPTION AREA IN ACCORD WITH H 62,20 WIS, ADMIZ411STRATION CODE. <br /> S O I L .B 0 R I N G S - MINIMUM 36" BELOki PROPOSED ABSORPTION SYSTEM <br /> BORING TOTAL DEPTH DEPTH TO GROUND WATER DEPTH TO BEDROCK <br /> NUMBER INCHES OBSERVED ESTIMATED OBSERVED ESTIMATED CHARACTER OF SOIL WITH THICKNESS IN INCHES <br /> EXAMPLE <br /> B 0 7211 728, CK0 OI w C 8"' " A " <br /> z <br /> 3 Y 4 �`Q' <br /> RECORD DATA FROM <br /> TYPE OF OCCUPANCY: <br /> RESIDENCE: NUMjER OF BEDROOM/S/ �CTHERs (SPECIFY) . / NUMBER OF PERSONS <br /> FOOD WASTE GRINDER: YES _NO v DISHWASHER: YES NOy AUTOMATIC CLOTHES WASHERS YES NO <br /> EFFLUENT DISPOSAL SYSTEM: NEW 4v� EXTENSION ADDITION REPLACEMENT <br /> TILE SIZE NO. LIN. FEET TRENCH WIDTH DEPTH NUMBER OF LINES <br /> SEEPAGE BED: LENGTH��WIDTH�� DEPTH TILE SIZE NO. LINES <br /> SEEPAGE PITS INSIDE DIAMETER LIQUID DEPTH <br /> I, the undersigned, hereby certify that the percolation tests reported on this form were made by me or under my super— <br /> vision in accord with the procedures and method specified in Chapter H 62.20 (3 ), Wisconsin Administrative Code, and <br /> that the dataf�focorded(amend loccattion o test holes are correot to the be t�f )cuowledge d belief. <br /> NAME I0 / 7���/ �V K TITLE s�Y -- <br /> TYPE or PRINT) / <br /> REGISTRATIONN NO. OR MASTER PLUMBER LICENSE NO. <br /> ADDRESS <br /> ,�DATE "' SIGNATURE <br /> NOT WRITE IN SPACE LO - FOR DEPARTMENT USE ONLY <br /> DATE RECEIVED ACCEPTED BY RETURNED <br /> FEE RECEIVED VALID NO. PIT NO, <br /> VIEWED BY APPROVED DATE <br /> „suf INITIALS YES OR NO <br />