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NAME s 17i4-V= /f e/n <br /> v COUNTY, /3vRNE/J <br /> - SEPTIC TANK PERMIT NUMBER, .39 a 23 <br /> REPORT ON SOIL PERCOLATION TEST <br /> AND SOIL BORINGS <br /> TO <br /> DIVISION OF HEALTH ... PLUMBING SECTION <br /> P.O.BOz 309, Madison, Wis. 53701 <br /> Pursuant to H 62.20, Wis. Administravive Cod. <br /> PERCOLATION TEST <br /> TEST DEPTH ' CHATACTEA OF SOIL HOURS WATER TEST TIME DROP IN WATER LEVEL INCHES MINUTES <br /> NUMBER INCHES THICKNESS IN INCHES SINCE HOLE IN HOLE INTERVAL SECOND TO NEXT TO LAST TO FALL <br /> lit WETTED OVERNIGHT IN MINUTES LAST PERIOD4.-LAST PERIOD PERIOD ONE INCH <br /> EXAMPLE <br /> P - 0 36" ?OP SOIL }0". CLAY 26" 25 YES OR NO 30 * 60 <br /> 34 ` -4--C,V y., 3 =• / = ije ? ice;_. G ' 3�; <br /> 1 1 <br /> G <br /> 2 y <br /> 3 /,� c V � * � G t ' :� <br /> >G / y '' ' ` <br /> 3 ' <br /> RECORD DATA FROM MINIMUM OF 3 TES? HOLES <br /> COMPUTE SIZE OF ABSORPTION AREA IN ACCORD WITH H 62.20 WIS., ADMINISTRATION CODE. <br /> S OIL BORINGS - MINIMUM 36" BELOW PROPOSED ABSORPTION SYSTEM <br /> BORING TOTAL DEPTH DEPTH TO GROUND WATER DEPTH TO 8EDROCK <br /> NUMBER INCHES OBSERVED ESTIMATED OBSERVED'ESTIMATED CHARACTER OF SOIL WITH THICKNESS IN INCHES <br /> EXAMPLE <br /> B - 0 Jr' 72" BLACK TOP SOIL 12", CLAY 18". SAND 18". GRAVEL 24" <br /> 2 rr <br /> y '- 6c <br /> 9 � 4 ' I GO <br /> 3 y <br /> RECORD DATA FROM MINIMUM OF 3 BORE ROLES 1 <br /> TYPE OF OCCUPANCY: <br /> RESIDENCE: NUMBER OF BE ROCt1S -- OTHER: (SPECIFY) NUMBER OF PERSONS <br /> FOOD WASTE GRINDER: YES Ni DISHWASHER: YES. NOV- AUTOMATIC CLOTHES WASHER, YE.� NO G� <br /> EFFLUENT DISPOSAL SYSTEM, NEW EXTENSION ADDITION REPLACEMENT <br /> TILE SIZE NO. LIN. FEET // ', TRENCH WIDTH DEPTH NUMBERNUMBER OF LINES <br /> SEEPAGE BED: LENGTA.2 t WIDt4lI ' DEPTHS ' TILE SIZt ' NO. LD <br /> SEEPAGE PIT, INSIDE DIAMETER LIQUID DEPTH <br /> I, the undersigned, hereby oertify that the percolation tests reported on this form were made by me or under mar super- <br /> vision in a000rd with the procedures and method specified in Chapter H 62.20 (3 ), Wisoonsin Administrative Code, and <br /> that the data recorded and location of test holes are correct to the be t�-emty knowledge d belief. <br /> NAME / , 1/1 t 5 II /�' 1 --TITLE /_- - - /37 y-4-- ‘--i --"' <br /> (TYPE or PRINT) ', <br /> REGISTRATION <br /> 9/�NO OR MASTER PLUMBER LICENSE NO. / <br /> ADDRESS /r/_ / ,-- <br /> DATE!d' - " / r-�-- SIGNATURE '' (-_ 2-- <br /> DO NOT WRITE IN SPACE- WW - FOR DEPARTMENT USE ONLYo .-► <br /> DATE RECEIVED ACCEPTED BY RETURNED <br /> FEE RECEIVED VALID NO. PERMIT NO. <br /> REVIEWED BY APPROVED DATE <br /> TV Tr.T.t c vrc no Yf1 <br />