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Name of Uwner _ t+ounty rermit No. <br />PERCOLATION TESTS <br />I, the undersigned, hereby certify that the Percolation Tests reported on this form were made by me or under my supervision <br />in accord with the procedures and method specified in Section H 62.20 (3), Wisconsin Administrative Code, and that the data <br />recorded and location of test holes are correct to the best of my knowledge an elief. <br />NAME L //If����t' TITLE <br />(Type or Print) <br />REGISTRATION NO. or MASTER PLUMBER LICENSE No. <br />ADDRESS <br />lA <br />DATE OF TEST '�C-11 SIGNATURE-r7t-�� <br />-------------------------------- ------------------------------------------------------------------------------------------------------------------------------------- <br />MASTER PLUMBER M ING APPLI TION /j MP <br />Signature: 6_222IC-1- a -7 License Number: MP RSW <br />For: E�� Provide sketch below of system <br />(employer) (Include direction and percent of slope and all applicable distances) <br />20' PLAN VIEW (Locatefercolation Test & Soil ,Bore _Holes) <br />- <br />15` / <br />10' <br />5' <br />r <br />5, <br />10, <br />15' <br />20' _ d <br />25' _ <br />MOO]Lt (Indicate Orodndwater or bedrock wl ere `,applicable) <br />7 <br />8 <br />9, <br />10' <br />11, <br />Note: The application cannot be considered for filing until all of the above questions are answered and the fee paid. <br />- - - ------------------------------------------------------------------------------- <br />Date of Application <br />Permit Issued/Rejected (date) <br />Issuing Agent Name <br />Do not write in space below - FOR DEPARTMENT USE ONLY <br />Fees Paid State <br />Inspection Yes <br />Valid No. <br />DIVISION OF, HEALTH, P.O. BOX 309, MADISON, WI. 53701 —Revised 4-1-73 <br />County <br />No — <br />Date Rec'd <br />.1 <br />