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EH 115 / t <br /> �\ p� iA.QNSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> D �, 1 .� ,`DlVeION OF HEALTH., BUREAU OF ENVIRONMENTAL HEALTH <br /> htr. ) .- t P.O. BOX 309 <br /> _ rti MADISON,WISCONSIN 53701 <br /> `J J REPORT ON SOIL BORINGS AND PERCOLATION TESTS <br /> LOCATION:3W'/e, 5,E%, Section 4q, TSN, R,1 B lot) W,Township or Municipality `� C e' <br /> Lot No- �, 11_g�k No. County <br /> T • I Subdivision N�t7�e <br /> Owner's Name: Vl^ /� d� G 1 (J n <br /> Mailing Address: 6 `' `� J ry T' r �`q � e <` I C', _V <br /> TYPE OF OCCUPANCY: Residence of Bedrooms 3 Other <br /> �LZ <br /> EFFLUENT DISPOSAL SYSTEM: NEW ADDITIOrN, REPLACEMENT <br /> DATES OBSERVATIONS MADE: SOIL BORINGS y— 7 a PERCOLATION TESTS 6 <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 SINCEHOLE HOLE AFTER INTERVAL <br /> BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN <br /> P-I ay" , N 1D / 0 <br /> P-a a,�,I ,( ( r <br /> P-3 q No lo .? S <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) �r <br /> e- NP SAF 1 �do%;a f <br /> 7 7 �h -ts b MIcd Soh c� <br /> PLAN VIEW (Locate percolation tests,soil bore holes and suitablesoil areas.) <br /> Indicate on the plan the location and square feet of sui1table a ea Ind Irate au of squareffeet of absorption area <br /> needed for building type and occupancy. (O/S- 'b f /�)re. d d e 1 cl Indicate scale <br /> or distances. Give horizontal and vertical reference points. Indicate slope. <br /> 1d' . <br /> — d .y <br /> — Inl71 <br /> d <br /> T 42a 2 <br /> f <br /> I <br /> i <br /> ,; p r# e�e� <br /> 41* — <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 kno ledge and belief. <br /> 1 <br /> Name (print) � t l`F � /G/) / '' C���n S Certification No. 3 •� <br /> Address �-O 7,-+" S �y <br /> Name of installer if known ✓ <br /> CST Signature <br /> COPY A—LOCAL AUTHORITY <br />