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� 5 <br /> WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> DIVISION OF HEALTH,13USEAU OF ENVIRONMENTAL HEALTH <br /> P.O.BOX 309 <br /> MADISON,WISCONSIN 53701 <br /> / JREPORlT ON SOIL BORINGS AND PERCOLATION TESTS <br /> LOCATION: �/., J 6,Section L'+ ,T y'N, R'q9!(or) W,Township or Municipality <j o <br /> Lot No. Block No. - County tj /• n C <br /> �, f ubdlvpion Name <br /> E r' <br /> Owner's Name:-(9 ` 1 0 t n / )) / <br /> Mailing Address: I .7 Y r 0 y <br /> TYPE OF OCCUPANCY: Residence X No.of Bedrooms Other --_� <br /> EFFLUENT DISPOSAL SYSTEM: NEW ) _ D- (0 __7 ? <br /> ADDITIONREPLACEMENT <br /> _ <br /> — D- � 7 ('-_PERCOLATION TESTS 7 — ~ 6 7 7 <br /> DATES OBSERVATIONS MADE: SOIL BORINGS_�/ I <br /> SOIL MAP SHEET SOI L TYPE <br /> PERCOLATION TESTS <br /> TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL,INCHES RATE <br /> NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/IN <br /> HER pp 1STWETTED SWELLING INMINUTES PERIOD 1 PERIOD 2 PERIOD <br /> P-zy if LL /a NO p � � <br /> SOIL BORING TESTS 0 <br /> TEST TOTAL DEPTH DEPTH TO GROUNDWATER.INCHES CHARACTER OF SOIL WITH THICKNESS,INCHES I <br /> NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) I <br /> PDLAN VIEW (Locate percolationtests,soll bore holes and suitable soil areas.) <br /> Indicate on the plan the location and square feet of lit le ar IPdicate n}��}bcr of s6uar feet of absorption area <br /> needed for building type and occupancy. �3 / y /`! 't'T D Indicate scale <br /> or distances. GIVQ horizontal and vertiC3 CC rQferen [5. Indicate SOpQ. - <br /> I� u P Irk <br /> N <br /> / r .g u <br /> i <br /> nc /L1or " " <br /> c. d 0 <br /> I I,the undersigned,hereby certify that the soil tests reported on this form were made by mein 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 belie�ff�. f. �7 <br /> r Name (print) —e�11 �P rl a I,' fL' ft-I' L P Certification No. </ <br /> Address O 'S / 4 rS'' C <br /> ( Name ofmmelle,if known Oda-fl'r� -l' - /''� <br /> CST Signature —1Y °" � ✓1- _ <br /> i COPY A-LOCAL-AUTHORITY <br />