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EH 115 <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 SOI L BORINGS AND PERCOLATION TEST7S� - <br /> LOCATION: <br /> 1 'NW'L, (f'G,Section <br /> {; T_% RISIP(or) W,Township or.Municipality, ,, <br /> Lot No. �. Block No. . _ty,_I � / r'e 9 rY 2 h Vey g 5e t�Courrtttry dY1 r ri e <br /> ..�) uUdivi i Name <br /> Owner's Name: 'r'e7 T,,- <br /> Mailing Address: C— 4 S t l`1 / 1 n� TV lam. SJ. �yv / ✓lsl irr �. S,j- / 0 6 <br /> TYPE OF OCCUPANCY: Residence x No.of Bedrooms Other —� <br /> EFFLUENT DISPOSAL SYSTEM: NEW X ADDITION REPLACEMENT <br /> - a � � �DATES OBSERVATIONS DE: %PERCOLATION TESTS <br /> � CfSOIL MAPSHEET <br /> SOIL TYPE <br /> PERCOLATION TESTS - <br /> TEST DEPt'H CHARACTER OF SOIL HOURS WATERIN TEST TIME DROP IN WATER LEVEL,INCHESRATE <br /> NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL - - <br /> BER- ISTWETTEO SWELLING INMINUTES PERIOD I PERIOD Z PERIOD 7 MIN/IN <br /> P Z '3 <br /> 5 ?6 / l i✓o � o �s � ��' 3 � <br /> SOIL BORING TESTS - <br /> TEST TOTAL DEPTH DEPTH TO GROUNDWATER,INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES <br /> NUMBER INCHES OBSERVED JESTIMATED HIGHEST )DEPTH TO BEDROCK IF OBSERVED) <br /> / l <br /> /-/(� rr r W JGhd G j <br /> - 7?}} rr % 7a r/ Gr/6./j r^ ItGXO(', r'h+ t• 0/ __ .1G% i/ <br /> Ol) rs �d Ylalr Q SgAd U_ <br /> PLAN VIEW (Locate percolationtests,soil bore holes and suitable soil areas.) <br /> _ Indicate on the plan the location and square feet of suijapI areas In )tate nuVpr of s yore 4t of absorption area _ 1 <br /> needed for building type and occupancy. 7/ C r /1J'P tQd P eL Indicate scale <br /> or distances. Give horizontal and vertical reference points. Indicate slope. - <br /> ;,, , 11 � cbC r� MorK <br /> err � f <br /> IFS <br /> pe s t <br /> N ( <br /> L <br /> t <br /> t <br /> 1 <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 Cade,and that the data recorded and location of test holes are correct I <br /> to the best of my(knowledge and belief. <br /> - Name(print) I ` 0 t/ F r 1 C- /\ / /-U!7 /1 //7f Certification No. <br /> Address— <br /> Name <br /> ddress Name of installer if known • - <br /> CST Signature <br /> COPY.A—LOCAL AIITHOgITY - - <br />