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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 TEST <br /> LOCATION: Ya, '/a,Section�-3,TYN, R'L/pfd(or) W,Town hi r Municipality. _s ° j <br /> Lot No. —/[—, Block No. , f�/PKr,f� ��4 ' l./ 7 County �/S �i 17- <br /> Su iyision Name <br /> Owner's Name: � `� �� ir/ 1. <br /> r <br /> Mailing Address: <br /> TYPE OF OCCUPANCY: Residence X No.of Bedroo Other <br /> EFFLUENT DISPOSAL SYSTEM: NEW X q ADDITION REPLACEMENT <br /> DATES OBSERVATIONS MADE: SOIL BORINGS S^ 7 � PERCOLATION TESTS 'f— �� <br /> SOIL MAP SHEET SOI L TYPE <br /> PERCOLATION TESTS <br /> TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE <br /> NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL <br /> BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN <br /> P- ( 6 3 1 'z L - <br /> 47;x/ 1 J <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 /> 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 n ber of square feet of absorption area <br /> needed for building type and occupancy. 'Q�� s �T Indicate scale <br /> or distances. Give horizontal and vertical reference points. Indicate slope. <br /> /e <br /> v/ <br /> � � n <br /> r s _ t <br /> IJ Ah <br /> Q G <br /> d r <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 k wledge and belief. / �j <br /> Name (pr;n+I.; �`�' , \—/ a Z_ Certification No. '1{/ <br /> Address �UT��k'c <br /> Name of installer if known F <br /> CST Signature <br /> COPY A—LOCAL AUTHORITY <br />