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I . Z <br />WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br />DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH <br />P.O. BOX 309 <br />MADISON, WISCONSIN 53701 <br />REPORT ON SOIL BORINGS AND PERCOLATION TESTS <br />LOCATION: %, '/4, Section _, T—N, R E (or) W, Township or Municipality <br />Lot No. , Block No. County <br />Owner's Name: <br />Mailing Address: <br />TYPE OF OCCUPANCY <br />Subdivision Name <br />Residence No. of Bedrooms <br />EFFLUENT DISPOSAL SYSTEM <br />DATES OBSERVATIONS MADE <br />SOIL MAP SHEET <br />NEW ADDITION <br />SOIL BORINGS <br />SO I L TYPE <br />PERCOLATION TESTS <br />Other <br />REPLACEMENT <br />PERCOLATION TESTS <br />TEST <br />NUM- <br />BER <br />DEPTH <br />INCHES <br />CHARACTER OF SOIL <br />THICKNESS IN INCHES <br />HOURS <br />SINCE HOLE <br />1ST WETTED <br />WATER IN <br />HOLE AFTER <br />SWELLING <br />TEST TIME <br />INTERVAL <br />IN MINUTES <br />DROP IN WATER LEVEL, INCHES <br />RATE <br />MIN/IN <br />PERIOD 1 <br />PERIOD 2 <br />PERIOD 3 <br />P— <br />B— <br />P— <br />P— <br />SOIL BORING TESTS <br />TEST <br />NUMBER <br />TOTAL DEPTH <br />INCHES <br />DEPTH TO GROUNDWATER, INCHES <br />CHARACTER OF SOIL WITH THICKNESS, INCHES <br />(DEPTH TO BEDROCK IF OBSERVED) <br />OBSERVED <br />ESTIMATED HIGHEST <br />B— <br />B— <br />B— <br />PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) <br />Indicate on the plan the location and square feet of suitable areas. Indicate number of square feet of absorption area <br />needed for building type and occupancy. Indicate scale <br />or distances. Give reference point. Indicate slope. <br />I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures <br />and methods specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct <br />to the best of my knowledge and belief. <br />Name (print) <br />Certification No. <br />Name of installer if known <br />Copy C — Local Authority <br />Signature <br />t IN <br />