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EH 115 '(11-74) <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: _'/., /.,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: SOILBORINGS '- - PERCOLATION TESTS - - <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 1SSNCE HOLE ST WETTED HSAFTERLE WELLINGIN MM <br /> VAL <br /> BER MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN <br /> P- <br /> f + _ <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 /> .--PLAN-VIEW, (L ocate <br /> -. _PLAN.VIEW..(Locate permlationtests,soil bore holes and suitable soil areas.)- <br /> Indicate on the plan the locationand 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 /> ♦ f / 0 <br /> _ -_ <br /> _ _ <br /> ilk- <br /> I,the undersigned,hereby certify that the sail 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) � / <br /> Signature <br /> Certification No. _ F <br /> Name of installer if known <br /> Copy C - Local Authority <br />