Laserfiche WebLink
EH 115 <br />WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br />DIVISION OF HEALTH, BUREAU' F ENVIRONMENTAL HEALTH <br />P.O. BOX 309 <br />MADISON, WISCONSIN 53701 <br />REPORT ON SOIL BORINGS AND PERCOLATION TE TS <br />LOCATION:, /4, j '/4, Section M, T�N, R "(or) W, Township or Municipal 4 4� ) c' 4/ <br />Lot No. , Block No. County��s- <br />Subdivision Name <br />Owner's Name: °= <br />n <br />Mailing Address: <br />TYPE OF OCCUPANCY: Residence _% Nco. of Bedrooms Other <br />�i <br />EFFLUENT DISPOSAL SYSTEM: NEW / __ADDITION REPLACEMENT <br />DATES OBSERVATIONS MADE: SOIL BORINGS �l�l Y'` 7 V PERCOLATION TESTS <br />SOIL MAP SHEET <br />SO L TYPE <br />PERCOLATION TESTS <br />TEST <br />DEPTH <br />CHARACTER OF SOIL <br />HOURS <br />WATER IN <br />TEST TIME <br />DROP IN WATER LEVEL, INCHES <br />RATE <br />NUM- <br />BER <br />INCHES <br />THICKNESS IN INCHES <br />SINCE HOLE <br />1ST WETTED <br />HOLE AFTER <br />SWELLING <br />INTERVAL <br />IN MINUTES <br />MIN/IN <br />PERIOD 1 <br />PERIOD 2 <br />PERIOD 3 <br />P r' <br />4 <br />. <br />Q <br />- <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 />B— <br />B-7,1 <br />i r <br />PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) <br />Indicate on the plan the location and square of suits I areas. Indicate number of square feet of absorption area <br />needed for building type and occupancy. � '✓1 Indicate scale <br />or distances. Give horizontal and vertical refereno4loghnts. Indicate slope. <br />t <br />� <br />a <br />r <br />1 <br />� <br />I, 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*owledge and belief. <br />Name (print) E!147 =� <br />Address ,� <br />Name of ins alter if known <br />Certification No.Y 7 <br />rnw a —I nf%Al Alff 1npiw CST Signature <br />