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I <br /> Name of Owner County Permit No. - <br /> PERCOLATION TESTS ` <br /> I, the undersigned, hereby certify that the Percolation Tests reported on this form were made by me or under my supervision <br /> in accord with the procedures and method specified in Section H 62.20 (3),Wisconsin Administrative Code,and that the data <br /> recorded and location of test holes are correct to the best of my knowledge and belief. <br /> NAME Joseph A. Meinholz . TITLE <br /> . (Type or.Print) <br /> REGISTRATION NO. or MASTER PLUMBER LICENSE No. 2968- <br /> ADDRESS Route 1 , Waunakee, Wi. 53597 <br /> 8-7-74 / / V . . <br /> DATE OF TEST : , SIGNATURE f1► 'iu . <br /> MASTER PLU diER:MAKIIVG APP TION , . .MP' • - • <br /> Signature: i' • i i..�//�� -. / License Number: MP RSW • 2968 ' ` - 'a <br /> For: Provide sketch below of system <br /> (employer) (� (Include dirty, rc nd percent of slope and all applicable distances) <br /> - • 1 r ; ,- , `1 . ..,.Ii'i° Ulit- ,--toff—I.... I - , <br /> 2O<• • . - i i .' i P_LAN.;V I.I W.(Locate.P eL�calatio Nest.&-Soil-B-ore FICles. L ' ' <br /> I I n C i yf - - 1 - <br /> .15f i I I i • IT 1 14--1 ' I_ ! 1 I i <br /> r I I i j ! I -- I <br /> i- <br /> a 5' i i l L � E <br /> ; i • - ..,! 1 c . . • I.. : t_i_.: . . .. 1 r I <br /> I <br /> •10 �•--1 1 l - ;- 1 ` <br /> �5 i 1 l ! I 1 i I 1- 1 ! I _ <br /> 1 1 j <br /> 25' . i I 11 I l I _i <br /> 1 ! I 11 I I • <br /> I I <br /> . _ I.P° •.0I Lq (.Indic jte_9r_o1Jndv/atel-o�bedrock w ere,Iapillica Ie)_i i I j . • <br /> -- -y I I <br /> i i - I I '- ' , ' ; I C..� � } ' f- - I <br /> ..2 -- 10l - - - _I .I _. j _ _ { -il --4 ;._ . } .1 - f- 1• <br /> 1 1 r � I I I I i I I : 'r 1 <br /> , � . � I � j 1 , - 4 - 1 . iI: <br /> • 1 <br /> 6i -I - <br /> T . I' 1 ' -( -- -� . I _.1 ! - - 1 : -- i i i, j- - i. _ : . Ii -11 <br /> ■ I I I I I I , 1 I I 1 I <br /> 1 i i ; I ,• i 1 i 1 I i• i z I i i <br /> —.9, • i I I I f ; j I. -f -[ . 1- , 1 -- I -t---1-- <br /> 1 j I i l i 1 1 i I I ' • I <br /> 10 J_.._.! I i i i j � - - - I .- . j. 7 -I ■ --1-- I - : -I I--i-- <br /> .1 ( _ . ...... s .i.___L. . _ s _ : L <br /> 1 ' Note: The application cannot be considered for filing until all of the above questions are answered and the fee paid. <br /> Do not write in space below—FOR DEPARTMENT USE ONLY - J (o/o/ <br /> •Date of Application 11-'3" 7 9 Fees Paid State 839 . <br /> I l— County oZb <br /> Permit Issued/R'ejected•(date) ~r 3- - i Inspection Yes - No " <br /> Issuing Agent Name Valid No. Date Rec'd <br /> DIVISION OF HEALTH,P.0.-BOX 309,MADISON,WI.53701—Revised 4-1-73 <br />