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,4 <br /> Name of Owne County; State 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 in <br /> accord with the procedures and method specified in Section H 62.20 (3),Wisconsin Administrative Code,and that the data <br /> recorded and loc ttiion�7off testst holes are correct to the best of my knowledge and ief. <br /> NAME /' /� J // /Vr— TITLE 1 /` <br /> (Type or Print) <br /> REGISTRATION NO. or MASTER PLUMBER LICENSE No. V 7 l <br /> r: <br /> ADDRESS f ,�"` <br /> DATE OF TEST v '� SIGNATURE• c.---- <br /> PERSON MAKING- PP ATIION ADDRESS <br /> ' _,/':(.."4-& <br /> SIGNATURE y .�/ �y <br /> • MASTER PLUMBER MAKI I TAL ATION 441031-'5.----- LICENSE NO. MPYG:3 <br /> SIGNATURE `t MPRSW <br /> Provide sketch below of system (Include direction and percent of slope and all applicable distances including well location and <br /> lot lines) <br /> PLAN VIEW (Locate Percolation Test&Soil Bore Holes) <br /> 164 <br /> . _ , 1,14" Api /44_44- <br /> ks Aa ,. 4-1.te--. <br /> 4044 <br /> "mar , p _ a 254,, 0 ._ _ do { /a <br /> ______)011 ,A4r-A/r <br /> _ . <br /> - .../` <br /> A/ <br /> 9 Y,4r 4114 - .-- <br /> UG <br /> 2q` . <br /> . t <br /> )"/A" got.L. , <br /> Note: The application cannot be considered for filing until all of the above questions are answered and the fee paid. <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 Date <br /> Issuing Agent Name Valid No. Date Rec'd. <br /> DIVISION OF HEALTH, P.O. BOX 309, MADISON,WI. 53701 — REVISED 3-1-74 <br />