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EH115 Rev.9/78 <br /> REPORT ON SOIL BORINGS AND PERCOLATION TESTS <br /> WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> P.O. BOX 309,MADISON,WISCONSIN 53701 <br /> LOCATION: "—'/<, .� ,._''/4,Section_,T—N,R_E (or)W,township or Municipality - <br /> Lot No. , Block No. County <br /> Subdivision Name <br /> Owner's/Buyers Name: /N A�� <br /> Mailing Address: ---r- " <br /> TYPE OF OCCUPANCY: Residence No.of Bedrooms COMMERCIAL <br /> EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT ALTERNATE SYSTEM OTHER <br /> DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS <br /> SOILMAPSHEET NOV VA&A&LFL NAME OF SOIL MAP UNIT <br /> PERCOLATION TESTS - <br /> TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL,INCHE RATE <br /> NUM- SINCE HOLE HOLEAFTEF INTERVAL <br /> BER INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD3 MIN/IN <br /> P— <br /> P— <br /> P— <br /> P— <br /> P— <br /> P— <br /> SOIL BORING TESTS <br /> TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR, <br /> TEXTURE,MOTTLING AND DEPTH TO BEDROCK <br /> NUMBER INCHES <br /> OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES <br /> B— <br /> B— <br /> B— <br /> B— <br /> B— <br /> PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas. <br /> Indicate number of square feet of absorption area needed for building type and occupancy ,Indicate scale or distances. <br /> Give horizontal and vertical reference points. Indicate slope. <br /> i <br /> 1 <br /> N <br /> 1,the undersigend,hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods <br /> specified in the Wisconsin Administrative Code,and that the data recorded and location of test holes are correct to the best of my <br /> knowledge and belief. <br /> Name (print) Certification No. <br /> Address <br /> .Name of installer if known <br /> CST Signature <br /> Copy B— Bureau of Environmental Health, Division of Health <br />