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74- <br /> Name of Owner 4 r C%((AX/f' County - /,, C� A'L'1 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 location ) <br /> of test holes are correct to the best of my knowledge and belief. <br /> NAME 1�' ,0,qt t ` /4of t ' 2- TITLE "?>/1/ .51,4) <br /> (Type or Print) <br /> REGISTRATION NO. or MASTER PLUMBER LICENSE No. c)3072,,, <br /> ADDRESS lf..t:' 'f r"-17 1,431t <br /> DATE OF TESTSIGNATURE!0— /7 7 - _ <br /> � <br /> G. •''*�- <br /> PERSON MAKING_ ate` / 1 6�t'7I ADDRESS 4 i . C4 60 s <br /> SIGNATURE-------%'�.f't� Z^f'i <br /> • - .�--10►'r '/C 3tn <br /> MASTER PLU KING INS Ttler}-. . /'` /" h 'L LICENSE NO. MP <br /> SIGNATURE_ .�,� MPRSW <br /> Provide sketch below of system (Include direction and perc nt of slope and all applicable distances including well location and <br /> lot lines) <br /> PLAN VIEW ((Locate Percolation Test&Soil Bore Holes) <br /> siv <br /> a <br /> r <br /> s IA, . <br /> S <br /> V <br /> 1...„............. ..<_ i <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 />