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- <br /> [O <br /> DEPARTMENT OF HEALTH AND SOCIAL SERVICES. DIVISION OF HEALTH <br /> (Pursuant to H 65.06,Wisconsin Atlministratwe Code) <br /> NAME OF SUBDIVISION <br /> CITY <br /> VILLAGE //����///����� ��������('' rj� �y 2g ,y/-�t E <br /> LOCATION OF SUBDIVISION: TOWN �OF(�'COUNTY J' 1' SECTION_: TOWN�`-' N: RANGE17—W <br /> (Clrxk One) <br /> NAME OF OWNER JC5 /le aVAZ <br /> ADDRESS 339 /5016S"T "-�ieEbE)21c W/. 54837 <br /> (Nymber b Speeo IN..) (Stats) (Zia COON <br /> NAME OF SUSOIVIOER 5/ 45;r <br /> ADDRESS <br /> (Number b StreeO (piece) ,1S tan) (/Zip Cobh <br /> SUBDIVISION WATER SUPPLY FROM: PUBLIC WATER SUPPLY PRIVATE WELLS>l <br /> SUBDIVISION DATA: AREA IN ACRES 6. 5 NUMBER OF LOTS 2 MINIMUM LOT AREA,SQUARE FEET-,T <br /> / <br /> DISTANCE TO NEAREST NAVIGABLE SURFACE WATER �J23o FEET. (IF WITHIN:S MILE) <br /> NAME OF LAKE OR STREAM OS/y�/✓// 44 A/ 10 wDa�Q VE <br /> RI 'P <br /> DATES OBSERVATIONS MAKE: SOIL BORINGS 4/,Jr/9G PERCOLATION TESTS <br /> SOIL BORING TESTS <br /> rtil 1brK ofK^ bewr^ro cwpywO wwri w. :vG^t3 CwwpwRMoe tlteM 3p tl t�Vtw wrtw tMCR Ms3s tw.w<^(S <br /> wyWtw I iNCM43 Oiilw V{D CST��wrt0^.c^t ST <br /> 72" >72" 10-4" J& Lmm 41j !L Bn A'l .' l6 361 BAa S w J"• <br /> e_ 3y"- 7211 L' h Fi A,Ir <br /> e- <br /> s• <br /> e <br /> e- <br /> e_ ) <br /> e- <br /> e- <br /> e- <br /> e- <br /> s- <br /> e- <br /> a- <br /> ,_ i <br /> e- <br /> e- I <br /> e- <br /> e- <br /> e- <br /> e- ' <br /> e_ <br /> e- <br /> e I <br /> NOTE: IF.SPACE IS INAOXOAJA.T.E.T.O REPORT ALL-SOIL BORINGS. USE AOIOITIONAL FORMS. <br /> AVER <br /> -$Eao <br />