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to <br /> DEPARTMENT OF HEALTH AND SOCIAL SERVICES,DIVISION OF HEALTH <br /> • (Pursuant to H 65.06.Wisconsin Administrative Code) <br /> NA,' E OF SUBDIVISION C`•'('m <br /> CITY <br /> VILLAGE A <br /> LOCATION OF SUBDIVISION: TOWN _OF s_0*COUNTY LWAL f SECTION OWN&0 N; RANG9J <br /> S W <br /> (Cheek One) <br /> NAME OF OWNER 6% QV LA[( <br /> ADDRESS S�4' I Vt -6✓I IYIh a/'J lh A. SS¢�7 <br /> INumoa.&Svaq fPIMH ISun) (Zip Coo.) <br /> NAME OF SUBDIVIDER <br /> ADDRESS <br /> (Numb.,S Street) (Place) -}5[aol y (Zip Cotlei <br /> SUBDIVISION WATER SUPPLY FROM: PUBLIC WATER SUPPLY PRIVAT WELLS .CX <br /> - <br /> SUBDIVISION DATA: AREA IN ACRES-2.1 NUMBER OF LOTS 2' MINIMUM LOT AREA.S UARE FEET <br /> DISTANCE TO NEAREST NAVIGABLE SURFACE WATER dkacfhl FEET.(IF IA(THIN A MILE) <br /> NAME OF LAKE OR STREAM Illh <br /> n Ua <br /> OATES OBSERVATIONS MAKE: SOIL BORINGS D �9r PERCOIATI ON TESTS <br /> SOIL BORING TESTS <br /> ns[ I [ot•t panty oar+w*p cwouwo w.[tw.:wcwta cw.w•ptaw or f•Cw SOK�•�lw w�twiroCKw ss�w�wcwas <br /> nu..eew :wcwts pestwv[o esn..•r[o w:cwts* <br /> a- 1 44' - >44 o.s „ � Sr'_44 rr f.ht 4. rngiLAV Q, s <br /> a- Y4 me III Ya p <br /> a- (lh;d L. t loo, ro.)ri 1-0 <br /> a• S ' >S3 0.5" 8h t/ S- .Ssw 'Hc 4,. Ned Z114t S <br /> a- <br /> Mf . Ss" <br /> Ma L,F /.or r-'II. uC <br /> a- <br /> a- <br /> a- <br /> e- <br /> a- <br /> a- <br /> a- <br /> a- <br /> ) <br /> a- <br /> a- <br /> a- <br /> a- <br /> a . <br /> a- <br /> a- <br /> a- <br /> a- <br /> _NOTd: IFAPAC!IS INAOEOUATE TO REPORT AL."01.1.EORINOS•USE AOIOITIONAL FORMS, MVE7[ <br /> SE" <br />