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WISCONSIN DEPARTMENT 0 _cl SOCIAL SERVICES
<br /> DIVISION OF HEALTH, BUTE -ski 7F ENVIRONMENTAL HEALTH
<br /> P.O. BOX 309
<br /> MADISON,WISCONSIN 53701
<br /> REPORTC/ ON SOIL BORINGS AND PERCOLATION TESTS
<br /> LOCATION:5ar'/o,s�Jl'/4,Section / l7/, T N, R 7 A.(or) W,Township Of 1l n�cipa its 3 " z•-� S.
<br /> Lot No. , Block No. County f.'Xr/ /7^
<br /> Owner's Name: { ` ; ,:I
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<br /> � Subdivision Name
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<br /> Mailing Address:76 '2- L/rlG.nR1 Acr4r, / 5-I f,99_,//— /.r/i'! ,_5-_370 �S
<br /> TYPE OF OCCUPANCY: Residence No. of Bedrooms Other
<br /> EFFLUENT DISPOSAL SYSTEM: NEW X ADDITION REPLACEMENT
<br /> 7'DATES OBSERVATIONS MADE: SOIL BORINGS / PERCOLATION TESTS 72 7c '
<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 SINCE HOLE HOLE AFTER INTERVAL
<br /> BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
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<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)
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<br /> PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
<br /> Indicate on the plan the location and square feet o suitab a reas. Indicate number of square feet of absorption area
<br /> needed for building type and occupancy. i ' /T7, •- Indicate scale
<br /> or distances. Give horizontal and vertical reference points. Indicate slope. "_'
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<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 m nowledge and belief.
<br /> Name (print z`'/� �► v�/ / tom/ �` Certification No. �.-
<br /> Address is �..2 '-=''.,`ems>'/ x,,L /3 - 73
<br /> Name f installer if known
<br /> CST Signature
<br /> COPY A—LOCAL AUTHORITY
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