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WISCONSIN DEPARTMEXTT, f HEALTH AND.SOCIALSERVICES <br /> i DIVISION OF HEALTH,BUREAU OF ENVIRONMENiAt HEALTH <br /> P.Q.BOX 309.- <br /> ,,OA�D,I'SONhWISCONSIN,03,701 , <br /> REPORT ON SOl;�s:asgrtlNGS AND`PERCO, ON TESTS <br /> LOCATION: i y., �I Y.,Section L.TSN. R ). P, <br /> �'(or. .W,Townshi orJiAuniapaill *�*- —R�7• ,� r�! <br /> Lot No. , Block No,—r# , County / <br /> 1vlslon me <br /> Owner's Name: 7,1 .r) M l E ti r r <br /> Mailing Address: '! <br /> TYPE OF OCCUPANCY: Residence �_ No.of Bedrooms < L Other <br /> EFFLUENT DISPOSAL SYSTEM: NEWI ADDITION REPLACEMENT <br /> DATES OBSERVATIONS MADE: SOIL BORINGS " PERCOLATION TESTS <br /> SOIL MAP SHEE 'rf's�� SOIL l < 1 • �i <br /> &V3 I PERCOLATION TESTS <br /> TEST DEPTH .CHARACTER OF SOIL HOURS WATER IN TEST IME DROP IN WATER LEVEL,INCHESRATE <br /> NUM- INCHES T#11CKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL _ <br /> BER 1STWETTED SWELLING IN MINUTES PERIOD 9 PERIOD 2 PERIOD.3 MIN/IN (� <br /> ) y <br /> ° !r ' lit <br /> a' <br /> SOIL BORING TESTS <br /> TEST TOTAL DEPTH" DEPTH TO GROUNDWATER,INCHES CHARACTER OF..SOIL WITH.THICKNESS, INCHES <br /> NUMBER INCHES OBSERVEDESTIMATED HIGHEST ,(DEPTH TO BEOROCICIF OBSERVEDI:;�.'µ <br /> 1 � al Op � � fV/fit ✓ 6`h cf <br /> �! � � r n /� - � � :a E oor J <br /> n <br /> PLAN VIEW (Locate percolation tests coil bore holes and suitable soil areas.) <br /> Indicate on the plan the location and square feet of jytable areas. .Indicyte npmber of square feet of absorption arse" <br /> needed for building type and occupancy. r L7 t� Y U+' Y d r d Indicate scale ' <br /> or distances. Give reference point. Indicate slope <br /> V r f Lt v s, 1 <br /> Y Q <br /> ii*vr er <br /> r I <br /> t• I for N.. <br /> VS <br /> / O <br /> f <br /> I,the undersigned,he y that the soil tests reported on this form were made by me in accord with the procedures <br /> and methods specifiediin the Wisotinsin Administrative Code;and that the data recorded and location of test holes are correct ' <br /> to the best of my knowledge and belief. <br /> ANameLA <br /> Name <br /> (print) Signature <br /> Certification No. <br /> Name of installer if known ' <br /> Copy C - Local Authority y <br />