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EH 115 111-74) <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 /> REPORT ON SOIL BORINGS AND PERCOLATION TESTS <br /> LOCATION: _'/o, %, Section , T—N, R— E (or) W, Township or Municipality <br /> Lot No. , Block No. County <br /> Subdivision Name <br /> Owner's Name: <br /> Mailing Address: <br /> TYPE OF OCCUPANCY: Residence No. of Bedrooms Other <br /> EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT <br /> DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS <br /> SOIL MAP SHEET SOIL TYPE <br /> PERCOLATION TESTS <br /> TEST DEPTH CHARACTER OF SOIL HOUR3 WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE <br /> NUM- INCHES THICKNESS IN INCHES 1SINCE ST WETNG <br /> OTED SWELLLE HOLE ING BINTERVAL <br /> ER IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN <br /> P— <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— <br /> B— <br /> B— <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 areas. Indicate number of square feet of absorption area <br /> needed for building type and occupancy. Indicate scale <br /> or distances. Give reference point. Indicate slope. <br /> ? N <br /> H ---411 FL111t <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 /> Name (print) Signature <br /> Certification No. <br /> Name of installer if known <br /> Copy C — Local Authority <br />