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EH 115 <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,/ '/4, Sectio , TVON, Rde #er�ownship o.Q&i irip@ility t -re a7- <br />Lot No. , Block No. /rjQ County E <br />// Subdivision Name <br />2 77 <br />Owner's Name: fc�60 S'G/ (e,�x7 <br />Mailing Address: A % <br />TYPE OF OCCUPANCY: Residence No. of Bedrooms Other <br />EFFLUENT DISPOSAL SYSTEM: NEW <br />I-- ADDITION <br />REPLACEMENT_ c <br />DATES OBSERVATIONS MADE: SOIL BORINGS �-. ;?- e;? -PERCOLATION TESTS 4 Q " - & •' <br />SOIL MAP SHEET <br />SOI L TYPE <br />PERCOLATION TESTS <br />TEST <br />NUM -SINCE <br />DEPTH <br />INCHES <br />CHARACTER OF SOIL <br />THICKNESS IN INCHES <br />HOURS <br />HOLE <br />WATER IN <br />HOLE AFTER <br />TEST TIME <br />INTERVAL <br />DROP IN WATER LEVEL, INCHES <br />RATE <br />ESTIMATED HIGHEST <br />B_ / <br />7A <br />BER <br />72 <br />B l is 'r's %71 k s _6A A 0, C S 119 <br />1ST WETTED <br />SWELLING <br />IN MINUTES <br />PERIOD 1 <br />PERIOD 2 <br />PERIOD 3 <br />MIN/IN <br />a 7 <br />A` <br />410 <br />P <br />`� ,� <br />1 <br />Mo <br />d�� <br />�' <br />l <br />SOIL BORING TESTS <br />TEST <br />TOTAL DEPTH <br />DEPTH TO GROUNDWATER, INCHES <br />CHARACTER OF SOIL WITH THICKNESS, INCHES <br />NUMBER <br />INCHES <br />(DEPTH TO BEDROCK IF OBSERVED) <br />OBSERVED <br />ESTIMATED HIGHEST <br />B_ / <br />7A <br />72 <br />B l is 'r's %71 k s _6A A 0, C S 119 <br />B-3 <br />2- <br />-7 <br />7 7-2- <br />B,c Is Ts 5, L3 may, Cs 40 <br />4s <br />a 7 <br />i s %40 C 3 <br />PLAN VIEW (Locate percolation tests,soi I 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. - 49 Indicate scale <br />or distances. Give horizontal and vertical reference points. 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) (21&-C"'L *rc'e 4&Certification No. %�- /7 a <br />Address Ae%/ 1. <SR'�1 �_��cE" �.c.)i S- <br />Name of installer if known <br />COPY A — LOCAL AUTHORITY CST Signature <br />tN <br />ONE <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) (21&-C"'L *rc'e 4&Certification No. %�- /7 a <br />Address Ae%/ 1. <SR'�1 �_��cE" �.c.)i S- <br />Name of installer if known <br />COPY A — LOCAL AUTHORITY CST Signature <br />tN <br />