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NAME: <br /> Comma <br /> SEPTIC TANK PERMIT NUMBERt <br /> REPORT ON SOIL PERCOLATION TEST <br /> AND SOIL BORINGS <br /> TO <br /> DIVISION OF HEALTH -PLUMBING SECTION <br /> P.O.BOX 309, Madison, Wis, 53701 <br /> Pursuant to H 62.20, Wis. Administravive Cods <br /> PERCOLATION TEST <br /> TEST DEPTH CHARACTER OF SOIL HOURS WATER TEST ?IMC DROP IN WAT R LEVEL INCHES MINUTES <br /> NUMBER INCHES THICKNESS IN INCHES SINCE HOLE IN HOLE INTERVAL SECOND TOEXT TO LAST TO FALL <br /> 1st WETTED OVERNIGHT IN MINUTES LAST PERIOD LAST PERIOD PERIOD ONE INCH <br /> EXAMPLE <br /> P - 0 3611 TOP SOIL 101% CLAY 2611 25 YES OR NO 30 60 <br /> I <br /> r _ <br /> 2 <br /> 3 d" , ., yon i- �. ,3 /, �: - r,. /, _ o , <br /> RECORD DATA FROM MINIMUM OF 3 TEST HOLES <br /> COMPUTE SIZE OF ABSORPTION AREA IN ACCORD WITH H 62.20 WIS, ADMINISTRATION CODE. <br /> S O I L -B 0 R I N G S - MINIMUM 36" BELOW PROPOSED ABSORPTION SYSTEM <br /> BORING TOTAL DEPTH DEPTH TO GROUND NATER DEPTH TO BEDROCK <br /> NUMBER INCHES OBSERVED ESTIMATED OBSERVED ESTIMATED CHARACTER OF SOIL WITH THICKNESS IN INCHES <br /> EXAM <br /> B - O7211 ° BLACK TOP SOILw CLAY 18111 SAND 1011, GRAVEL 24" <br /> p r / <br /> 2 y, <br /> RECORDA A <br /> FROK MINIMUM OF 3-BORK HOLES- <br /> TYPE OF OCCUPANCY: <br /> RESIDENCE: NUMBER OF BEDROOMS OTHER, (SPECIFY) NUMBER OF PERSON <br /> FOOD WASTE GRINDER: YES—NO DISHNASHERs YES_ N01G AUTOMATIC CLOTHES WASHER: YESG" NO <br /> EFFLUENT DISPOSAL SYSTEMt NEW_ EXTENSION— ADDITION_REPLACEMENT <br /> TILE SIZE_ NO. LIN, FEET TRENCH WIDTH DEPTH NUMBER OF LINES <br /> / <br /> SEEPAGE BED: LENGTH1L WIDTH -71 DEPTH_ I TILE SIZE / NO. LI'NES..�,_ <br /> SEEPAGE PITC INSIDE DIAMETER LIQUID DEPTH <br /> I, the undersigned, hereby certify that the percolation tests reported on this form were made by me or under M super- <br /> vision in accord with the procedures and method specified in Chapter H 62.20 (3 ). Wisconsin Administrative Code, and <br /> that the data <br /> /recorded and location of test holes are correct to the +be oP my knowledgeand belief. <br /> / <br /> NAME / , !? � fiF TITLe <br /> TTT TYPE or PRINT _ <br /> REGISTRATION NO. OR MASTER PLUMBER LICENSE NO. <br /> ADDRESS <br /> DATE /.Y %/r ] i�J- SIGNATURE <br /> DO NOT WRITE IN SPACE PART'MENT USE ONLY <br /> DATE RECEIVED ACCEPTED BY RETURNED <br /> PEE RECEIVED VALID NO. PERMIT NO. <br /> REVIEWED BY APPROVED DATE <br />