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_ - PH /45 (1174) <br /> WISCONSIN DEPARTMENT OF:HEALPH AND SOCIALSERVICES - <br /> DIVISION OF HEALTH,BUREAU OF ENVIRONMENTAL HEALTH <br /> P.O.BOX 209 <br /> MADISON,WISCONSIN 53701 <br /> REPORT ON SOIL BORINGS AND PERCOLATION TESTS <br /> LOCATION: —'/., —'/.,Section T=N, R_ E (or)W, Township or Municipality- _ <br /> Lot No. , Block No. County <br /> - Subdivision Name <br /> Owner's Name: _ <br /> Mailing Address: <br /> TYPE OF OCCUPANCY: Residence No.of Bedrooms Other - <br /> EFFLUENT DISPOSAL SYSTEM: NEW < ADDITION —REPLACEMENT <br /> DATES OBSERVATIONS MADE: SOIL PORI NGS PERCOLATION TESTS <br /> i <br /> SOIL MAP SHEET SOIL TYPE <br /> r . <br /> PERCOLATION TESTS <br /> TEST DEPTH CHARACTEROFSOIL HOURS WATER IN TESTTIME DROP IN WATER LEVEL,INCHES RATE <br /> NUM- INCHES THICKNESS IN INCHES - SINCE HOLE HOLE AFTER INTERVAL Ni <br /> BER 1STWETTED SWELLING INMINUTES PERIOD 1 PERIOD 2 PERIOD 3 <br /> P-• { \ ( f <br /> P_. i- <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 OBSERVEDI <br /> . yi <br /> / <br /> PLANVIEW Locate percolstiontests,soil bore holes and s uiumlesoil areas.) <br /> Indicate on the plan the location and square feet of suitable areas. -Indicate number of square feet of absorption area <br /> needed for building type and occupancy. v- IV - i Indicate scale <br /> ordistances. Give reference point. Indicateslope. .'�. <br /> 7 <br /> i <br /> 1 f f•_ <br /> V s. <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 my knowledge and belief. J , <br /> Name (print) Ic" r1 - 1'� r r f' Signature <br /> J <br /> Certification No. <br /> Name of installer if known <br /> Copy C - Local Authority <br />