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Name of Owner County " 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 of test holes are correct to the best of my knowledge and belief. <br /> NAME TITLE <br /> (Type or Print) <br /> REGISTRATION NO. or MASTER PLUMBER LICENSE No. <br /> ADDRESS <br /> DATE OF TEST SIGNATURE <br /> PERSON MAKING APPLICATIONS., _ r r��h- ��s ,} ADDRESSp— <br /> SIGNATURE <br /> MASTER PLUMBER MAKING INSTALLATION LICENSE NO. MP <br /> SIGNATURE MPRSW <br /> - �=: Y <br /> Provide sketch below of system (Include direction and percent of slope and all applicable distances including well location and <br /> lot lines) <br /> PLAN VIEW (Locate Percolation Test&Soil Bore Holes) <br /> i <br /> i <br /> Note: The application cannot be considered for filing until all of the above questions are answered and the fee paid. <br /> -- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <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 />