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Name of Owner County Permit No. . .a • <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 the best of my knowledge and belief. n <br /> NAME l d j! t ' f'/fRide / TITLE //I AiTf4 f%//4..3E ' <br /> (Type or Print) <br /> REGISTRATION NO. or MASTER PLUMBER LICENSE No. f' <br /> ADDRESS y/jii7ie- ©Me l,D 7 f4 C 'fi/C• jj//Se ' <br /> DATE OF TEST /0/?5/7 SIGNATURE X i 4' / <br /> MASTER PLUMBER MAKING APPLICATION .' MP '��9 . <br /> Signature: K 47x. i 4.' . fr License Number: MP RSW <br /> For: if Provide sketch below of system <br /> (employer) (Include direction and percent of slope and all applicable distances) <br /> I PLAN_N/ : _(Locate 'et.. • • .Test&SoiliBor His --+ 1. 14- 1 <br /> � 1 <br /> ,; ll I ; • � i 1 i <br /> ! ! i� _ . k — <br /> I p <br /> _i4 i l 0 <br /> j <br /> I i <br /> i y ,fib <br /> -26' ! i f C.- _�. 1 j 1 1 ... <br /> . 'WGI -7. i <br /> ■ r <br /> �� • es��_ '� r�ic d ,SC �� <br /> 1 <br /> L <br /> P. a -I L I I niricate rnun ater_or ibeoci._uvt�ere lapgli • - ! <br /> -t 1 ,_ I . + +. . <br /> a <br /> I 1 i <br /> _ I. I j .._.. . _�__ I ; i-- <br /> k% iii... <br /> -- \ sip <br /> I i i- it <br /> ,- afore- (1 vr_ 1 i <br /> , <br /> i ' f i1 � t i - - I 1 I <br /> ! <br /> {{ <br /> Note: The application cannot be considered for filing until all of the above questions are answered and the fee paid_ <br /> not write in space below—FOR DEPARTMEN't'USE ONLY a i <br /> Date of A6plicatioi /d w�G /"2 Fees Paid-State /4 ff� -�- County,?6 '" <br /> Permit Issi ed/Rejected(date), ''' 3A 7 ' Y Inspection Yes) .l No \'' <br /> Issuing Agent Name_ idio `' '--- I Valid No. Date Rec'd <br /> DIVISION OF HEALTH,P.O..BOX 309,MADISON,WI.53701—Revised 4-1-73 <br />