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NAME: . <br /> , <br /> COUNTY: <br /> SEPTIC TANK PERMIT NUMBERS <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 Code <br /> PERCOLATION TEST <br /> TEST DEPTH ' CHARACTER OF SOIL HOURS WATER TEST 'PIME DROP IN WATER LEVEL INCHES MINUTES ' <br /> NUMBER INCHES THICKNESS IN INCHES SINCE HOLE IN HOLE INTERVAL SECOND TO VEXT TO LAST TO FALL <br /> 1st WETTED OVERNIGHT IN MINUTES LAST PERIOD4LAST PERIOD PERIOD ONE INCH <br /> EXAMPLE <br /> P - 0 36" TOP SOIL 10", CLAY 26" 25 YES OR NO 30 4 4 4 60 <br /> 1 ,Y` C 7 � ,'c Nri G /(/v /a `f `1 - <br /> r 2 ' IL L //f /t N y ,, <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 OIL B 0 R I N G S - MINIMUM 36" BELOW PROPOSED ABSORPTION SYSTEM <br /> BORING TOTAL DEPTH DEPTH TO GROUND WATER DEPTH TO BEDROCK <br /> NUMBER INCHES OBSERVED ESTIMATED OBSERVED ESTIMATED CHARACTER OF SOIL WITH THICKNESS IN INCHES <br /> EXAMPLE <br /> B - 0 72"- 72" _ BLACK TOP SOIL 12": CLAY 18": SAND 18". GRAVEL 24' <br /> L , J <br /> 2 t r Ir I r I % <br /> RECO' 1A A :Ov v . to t: , .•: .. <br /> TYPE OF OCCUPANCY: <br /> RESIDENCE: NUMBER OF BEDROOMS sr OTHER: (SPECIFY) NUMBER OF PERSONS <br /> FOOD WASTE GRINDER: YES NO DISHWASHER: YES_-NO AUTOMATIC CLOTHES WASHER: YES <br /> EFFLUENT DISPOSAL SYSTEM: NEWy EXTENSION ADDITION. REPLACEMENT <br /> TILE SIZE NO. LIN. FEET TRENCH WIDTH DEPTH NUMBER OF LINES <br /> SEEPAGE BED: LENGTH I7,` t WIDTH I DEPTH .� r TILE SIZEL/ '/ NO. LINES ,,' <br /> SEEPAGE PIT: INSIDE DIAMETER LIQUID DEPTH <br /> I, the undersigned, hereby certify that the percolation tests reported on this form were made by me or under my 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 recorded and location of test holes are correct to the best of my knowledge and belief. <br /> NAME fr` Af, T/4AS 0A TITLE <br /> (TYPE or PRINT) <br /> REGISTRATION NO. OR MASTER PLUMBER LICENSE NO. le' S"'� <br /> ADDRESS ./Cr / S )/ ) 1/i 5 3 <br /> DATE Wil"' //°' 2) SIGNAT ' _ A/ J -e-a <br /> DO NOT WRITE IN SPACE BELOW - FOR DEPARTMENT USE ONLY <br /> DATE RECEIVED ACCEPTED BY RETURNED <br /> FEE RECEIVED VALID NO. PERMIT NO. <br /> REVIEWED BY APPROVED DATE <br /> INITIALS WC no un <br />