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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 /> b(I Zvi �P., REPORT ON SOIL BORINGS AND PERCOLATION TESTS <br /> LOCATION: %, Ya,Section T4 , R 45E (or) W,Township or Municipality <br /> Lot No. —L7—, Block No. ----pP, 'S�lk_�f County �'/� "lrt <br /> Owner's Name: <br /> 'T <br /> Mailing Address: i-:�:o )p`� C <br /> TYPE OF OCCUPANCY: Residence No. of Bedrooms Other <br /> EFFLUENT DISPOSAL SYSTEM: NEWS ADDITION REPLACEMENT <br /> DATES OBSERVATIONS MADE: SOIL BORINGS 4' ( — 77:2 PERCOLATION TESTS 6 f _7� <br /> SOIL MAP SHEET SO L TYPE e <br /> PERCOLATION TESTS <br /> TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL,INCHES RATE <br /> NUM- SINCE HOLE HOLE AFTER INTERVAL <br /> INCHES THICKNESS IN INCHES BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN <br /> P ' � i tom! t }E 17 /�''C s3 Cp I , ,f4 <br /> P- j► 17 w e `r <br /> E�l 11ye-1 <br /> SOIL BORING TESTS <br /> TEST TOTAL DEPTH DEPTH TO GROUNDWATER,INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES <br /> NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) <br /> - a <br /> B- 7X `/ <br /> B- 3 7�4%1 -7Z If <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 o square feet of absorption area <br /> needed for building type and occupancy. )Y Indicate scale <br /> or distances. Give horizontal and vertical reference points. Indicate slope. <br /> S <br /> 1�5 <br /> yr � <br /> ©, YJ <br /> D r <br /> I <br /> f <br /> O' t N <br /> x �y 4 <br /> IDS �i 15 <br /> us <br /> j <br /> f <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) Certification No. <br /> Address "D OLP j si� 1 � �ti ' 15"t'l d'a y <br /> Name of installer if known , <br /> CST Signature. <br />