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Name of Owner W4-:SbCounty Rv R N N 7T 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 <br /> in 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 �•I% S� L� IZ���l TITLE <br /> (Type or Print) ��77��� GG <br /> REGISTRATION NO. or MASTER PLUMBER LIC�I W..1lr�3 <br /> ADDRESS R 0, I 'S45'1I -7 <br /> DATE OF TEST h - 3 7 SIGNATURE - <br /> _ ---.-___...._-__--------- ------------ .-------- .__--------------------------------------- <br /> .1 / ... <br /> MASTER PLUMBER <br /> /��jAKIN AAPPL,IICAA®TIION /J MP 3 �D <br /> sSignature: ✓'p"' v""l�y✓"U'L�J License Number: MP RSW <br /> For: Provide sketch below of system <br /> (employer) �I- Occlude direction and percent of slope and all applicable distances) <br /> 20' — - P.LAN.VIEW-(Locate.Permlation.Test&.Soil Bore Holes) <br /> r— <br /> _5-_._.- - <br /> -01 <br /> —5I--— - - - - - --; - 93'-�-'• S r l uf� <br /> 20'- <br /> -25'- <br /> 11 <br /> 25' <br /> __ PPOF,ILE.(Indicate.Groundwater_�ubedrock.W ere!applicable) - - <br /> t <br /> o 42L fr <br /> Sn fp 4AM <br /> —3� — _ _ , ei •�) „':�•�4CChEGiNtF <br /> - - - - - - _ <br /> -91 <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 <br /> Issuing Agent Name - Valid No. Date Recd <br /> DIVISION OF HEALTH,P.O.BOX 309,MADISON,W L 53701 -Revised 4 143 <br />