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WISCONSIN DEPARTMENT OF-HEALTH AND,SOCIAL SERVICES <br /> DIVISION OF HEALTH PUP.EAL OF ENVIgONMENTAL HEALTH a <br /> BOX 306 - 'K <br /> y .. <br /> MADISON,:WISCONSIN .53701 r �" <br /> REPORT ON SOIL BORINGS AND PERCOLATION TESTS <br /> ,LOCATION ? TqAN-RfCE (orW;`Townslhip or.—Municipality c s n <br /> 1 <br /> Lot Ni:I Block No'. County -�• '1'� - <br /> Subdrvivon Na <br /> Own 's Name _\ \ r r a'•"-me <br /> M Iing:Addess 2.r: t� .r r ��'.� n!'n �4.al Cr V •j S �C!'O { G D - <br /> TYPE OFOCCUPANCV: Reside ce _ !r' No. of Bedrooms Other <br /> EFFLUENT DISPOSAL SYSTEM. NEWgDDIT10N 'REPLACEMENT" ' f , <br /> DATES OBSERVATIONS MADE- ,SOIL 86RINGS' Q 'Ind — OpERCO_LATION'TESTS <br /> SOIL^MAPSHEET - � `'�^ '�'�" 301LTVPE � N�A- V}'1 �Q LOC,M �y _ <br /> l <br /> PERCOLATION T_ ESTS - - - <br /> TEST' DEPM °CHARACTEROF SOIL ""HOURS ? .WATER IN TEST TIME DROP IN'WATER LEVELINCHES ggTE ; <br /> NUM INCHE THICKNESS.IN INCHES SINCE HOLE HOLE AFTER .INTE8VAC "`- " ' <br /> BEfi 1ST WETTEO 'SWELLING IN MINUTES PERIOD 1 PERI00 2 PERIOD 3 MIN/IN <br /> — <br /> 3S oto' <br /> SOIL BO RING.TESTS <br /> TEST'"( TOTACDEPTH 'DEPTH TOGROUNDWATER INCHES ,` CHARACTEROFSOILWITH THICKNESS INCHES <br /> NUMBER .- INCHES - _OBSERVED " ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED), <br /> l {Z _ 4 t ( pGr �c ' ft .5- <br /> Z: <br /> -2 �z: <br /> tI <br /> PLAN VIEW (Locate percolat ontests,ioil bore holes and suitable soil areas i <br /> Indicate on the plan[fie location and square feet ofsuitable areas Ihdinte number of square feet of absorption arez~, s <br /> needed for.building type and occupancy., <br /> 7 C t 4 <br /> _ ' Ind tate wale <br /> or distances Glve reference point Indicate slope./'QI�� <br /> plc <br /> a ._ _ _ \ <br /> Pj <br /> r <br /> � I <br /> k <br /> i <br /> a I;the undersigned;hereby cert ify,that the soil tests.reported on this form were made by me in'acmrd with the procedures <br /> and methods specifiedlathe Wisconsin•Administrative Code;and that the'datarei»rded'and location of test ole <br /> are correct <br /> to the_best of my knowledge and belief <br /> S <br /> Name (pnntl `r/11 c "(' <T` eSignature <br /> Tic91'". .�'i /! .mac <br /> .rtificatlorr Na ^'* , <br /> � Name of installer s rf known �'f•_ 1 13 t th <br /> C py G'-iL-cal AotM1_oritY 'T' - - Y•�- - a <br />