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w - — TT <br /> • ) . .11. • .• <br /> Name of Owner County State Rerm t No. 7•4J '. ... <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 in <br /> 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 /> aF <br /> V 6{ e f ' i l v ,G;- r TITLE /1..41�.+.•J: ,,,,�+' s r?v�+'r� r <br /> NAME }' � ,�,,, . � �� �: ` <br /> (Type or Print) <br /> REGISTRATION NO. or MASTER PLUMBER LICENSE No. f y.aw <br /> I ADDRESS � <br /> �d t SIGNATURE i +=4e ' r «4,a# .•::.,.r. . <br /> v <br /> DATE OF TEST �� <br /> PERSON MAKING APPLICATION ve.1=t w-` ADDRESS <br /> SIGNATURE ,t., - t .. * « 4 <br /> MASTER PLUMBER MAKING INSTALLATION LICENSE NO MP t :-ti <br /> .°-'F SIGNATURE /' 'i''i,'.I .,Ie. ,.+ f .ii''•;rte! A+'; MPRSW <br /> • <br /> Provide sketch below of system (Include direction and percent of slope and all applicable distances including well location and <br /> lot lines) ZD7'e s PLAN VIEW(Locate Percolation Test&Soil Bore Holes) <br /> a II <br /> F.. I. <br /> 6 <br /> zor • <br /> ill 11' -(- ....... i <br /> r <br /> _ lb ILIA .1.a i <br /> I1:; !Tiia lit 314//1 i1I <br /> IMPIEftit1i <br /> - X11,.!!! Tr <br /> pfl 7• 41 pi <br /> Note:The application cannot be considered for filing until all of the above questions are answered and the fee paid. <br /> Do rrot write in space below- FOR DEPARTMENT USE ONLY#/y 2.b ' �6.5(o Z <br /> Date of Application /7-if- 7 1 Fees Paid State /_ County a - <br /> Permit Issued/Rejected (date) - y' 7 - Inspection Yes No Date <br /> Issuing Agent Name Valid No. Date Rec'd. <br /> DIVISION OF HEALTH,P.O. BOX 309,MADISON,WI.53701 - REVISED 3-1-74 <br /> A <br />