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NAME: 1 ttt -+...ei.A. <br /> COUNTY: ilpck-ue=411- <br /> . <br /> SEPTIC TANK,PERMIT NUMBERS <br /> REPORT ON SOIL PERCOLATION TEST <br /> AND SOIL BORINGS <br /> TO <br /> DIVISION OF HEALTH - PLUMBING SECTION <br /> P.O.BOX 309, Madison, Wis. 53701 <br /> Pursuant to H 62.20, Wis. Administravive Code <br /> PERCOLATION TEST <br /> TEST ' DEPTH CHARACTER OF SOIL HOURS WATER TEST TIME DROP IN WATER LEVEL INCHES MINUTES r <br /> NUMBER INCHES THICKNESS IN INCHES SINCE HOLE IN HOLE INTERVAL SECOND TO IJEXT TO LAST TO FALL <br /> 1st WETTED T OVERNIGHT IN MINUTES LAST PERIODRLAST PERIOD PERIOD'ONE JINCJ <br /> EXAMPLE <br /> P + 0 O TOP SOIL 10" CLAY 26+' / JA YESb NO 30 3 ,,, _�-, 60 a <br /> 1 -3 <br /> 2 3 d ,31 9 �4.. , R 2 i -3 - I. <br /> 3 d 37 I ' '' `''3 <br /> 17- <br /> RECORD DATA FROM MINIM OF 3 TEST HOBS <br /> I COMPUTE SIZE OF ABSORPTION AREA IN ACCORD WITH H 62.20 WIS., ADMINISTRATION CODE. v u t1T T4 3 MI 4• <br /> S OIL BORINGS • MINIMUM 36" BELOW,PROPOSED ABSORPTION SYSTEM <br /> BORING TOTAL DEPTH DEPTH TO GROUND WATER DEPTH TO BEDROCK <br /> NUMBER INCHES OBSERVED ESTIMATED OBSERVED ESTIMATED CHARACTER OF SOIL WITH THICKNESS IN INCHES <br /> EXAMPLE <br /> B • 0 72' 72" BLACK TOP SOIL 12"( CLAY M". SAND 16". GRAVEL 21" <br /> Y 6 6( 13 v ,,,,,..4-4,,,.0.„, 3 4 3 <br /> 2 / d 13o 3 / 77 <br /> 3 „ ee( _ !341 3 (<3 <br /> #IECQ DATA FROM MINIMUM OF 3 BORE HOLES <br /> TYPE OF OCCUPANCY: r_ <br /> RESIDENCE: NUMi3ER OF BEDROOMS OTHER: (SPECIFY) NUMBER OF PERSONS. <br /> FOOD WASTE GRINDER: YES NO DISHWASHER: YES NO AUTOMATIC CLOTHES WASHER: YES NO <br /> EFFLUENT DISPOSAL SYSTEM: NEW )( EXTENSION ADDITION REPLACEMENT <br /> TILE SIZE NO. LIN. FEET TRENCH WIDTH DEPTH NUMBER OF LINES <br /> SEEPAGE BED: LENGTH 1C WIDTH /C / DEPTH -UTILE SIZE IV "NO. LINES <br /> SEEPAGE PIT: INSIDE DIAMETER LIQUID DEPTH <br /> • <br /> I, the undersigned, hereby certify that the percolation tests reported on this form were made by me or under my super- <br /> vision in accord with the procedures and method specified in Chapter H 62,20 (3 ), Wisconsin Administrative Code, and <br /> that /the data recorded and location of test holes are correct to the best of my knowledge and belief. <br /> NAME kL 3ti1' 7-e-4 -1) k TITLE <br /> (TYPE or PRINT) • <br /> REGISTRATION NO. OR MASTER PLUMBER LICENSE NO Q9 3J <br /> ADDRESS S P — t.' r . tj 42-7 'j - <br /> DATE //- !3 ~�� SIGNATURE "1 _ j7e <br /> DO NOT WRITE IN SPACE BELOW • FOR DEPART MUSE ONLYj <br /> DATE RECEIVED ACCEPTED BY RETURNED <br /> FEE RECEIVED VALID NO. PERMIT NO. <br /> REVIEWED BY APPROVED DATE <br /> INITIALS YES OR NO <br />