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.F ;1 <br /> NAME: <br /> COUNTY, <br /> SEPTIC TANS PERMIT NVMBERs <br /> REPORT ON SOIL PERCOLATION TEST <br /> AND SOIL BORINGS <br /> TO <br /> DIVISION OF HEALTH — PLUMBING SECTION <br /> P,O.BOX 309, Madison, Nis, 53701 <br /> Pursuant to H 62.20, Wis. Administravivs Cods <br /> PERCOLATION TEST <br /> TEST DEPTH CHARACTER OF SOIL HOURS NATER TEST TLMB DROP IN NATER LEVEL INC f65 MINUTES <br /> NUMBER INCHE THICKNESS IN INCHES SINCE HOLE IN HOLE INTERVAL SECOND TO EXT SO _ LAST TO PALL <br /> 1st NETTED - OVERNIGHT 3N MINUTES CAST PERIOD LAST PERIOD PERIOD ONE INCH <br /> EXAMPLE <br /> P — 0 3611 TOP SOIL 1O^ CLAY 26I11�y 25 YES OR NO 300 60 <br /> 1 I^ /o"n "-A `i 9.1,.1 'L 2'� N U �1. � <br /> 2lo <br /> RECORD DATA FROM MINIMOM OF 3 TEST HOLES <br /> COMPUTE SIZE OF ABSORPTION AREA 1N ACCORD WITH H 62,20 NIS. ADMINISTRATION CODE. <br /> S O I L B 0 R I N G S - MINIMUM 36° BELM PROPOSED'ABSORPTION SYSTEM <br /> BORING TOTAL DEPTH DEPTH TO GROUND HATER DEPTH TO BEDROCK <br /> NUM3ER INCIGS OBSERVED ESTIMATED ODSERVCD ESTIMATED CHARACTER OF SOIL WITH :NICENESS IN INCHES <br /> UAMPLA <br /> B - 0 K TOP SOILCLAY 181% SAND 18c, GRAVEL <br /> .r <br /> r 'TA . <br /> TYPE OF OCCUPANCY: <br /> RESIDENCE: NUMBER OF BEDROCKS '�_ OTHER: (SPECIFY) NOlJ3E11 OF PERSONS <br /> FOOD WASTE GRINDER: ,YES . NO I/ DISHWASHER: YES_ NO 1� AUTOKATIC CLOTHES WASHER, YES_ NO <br /> EFFLUENT DISPOSAL SYSTEM, N£N% EXT ENSIGN ADDITION REPLACIMENT <br /> TILE SIZE N0, LIN, FEET_ TRENCH 'WIDTH_DEPTH_ NUMBER OF LIMES_ <br /> SEEPAGE BED: LENGTH L V WIDTH HO I DEPTH 3'L 1 TILE SIZE_NO, LINES <br /> SEEPAGE PITS INSIDE DIAMETER LIQUID DEPTH <br /> I, the und...Ig sd, hereby certify that the percoleticn tests reported on this farm were red. by me or under W 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 .f test holes are correct to the b//eat of 3' Eacwled6e and ballet. <br /> NAME r-Nt,1'G S-f%u-9C 1<" TITLE /T!S. sGY PIN., .,r LJ C. rA <br /> TYPE or PRINT) <br /> REGISTRATION NO, OR MASTER PLUMBER LICENSE NO. ,N y <br /> ADDRESS I'—). UG✓ (• % /✓CIO•+`GY.L�� IS .r---�-- <br /> DATE G• `-n -T SIGNATURE <br /> DO NOT WRITE IN SPACE BELOW — TOR DEPARTMENT USE ONLY <br /> DATE RECEIVED ACCEPTED BY RETURNED <br /> PEE RECENED VALID NO. PERMIT NO. <br /> REVIEWED BY "PROM DATE <br /> INITIALS _ _ YES OR NO <br />