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.`. 4 <br /> .. <br /> Name of Owner County State Permit No. - I' ..' <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 /> NAME TITLE <br /> (Type or Print) <br /> REGISTRATION NO. or MASTER PLUMBER LICENSE No. <br /> ADDRESS /12/- n.. e-o7"?Vl4 0 A'i ' , 14/1 S 53.5 2'7 <br /> DATE OF TEST SIGNATURE <br /> PERSON MAKING APPLICATION ADDRESS <br /> SIGNATURE <br /> MASTER PLUMBE MAKING INSTALLATION - A • ! . L. LICENSE NO. MP OQ44S- <br /> SIGNATURE , 1 -i14-y.. // MPRSW <br /> Provide sketch ow of system (Include direction and percent of slope and all applicable distances including well location and <br /> lot lines) <br /> PLAN VIEW (Locate Percolation Test&Soil Bore Holes) <br /> 14,7 f <br /> r3' <br /> cc. fv.✓/'>b/4 <br /> - i <br /> k .. - �` <br /> 31 4' 4' 3 c. . <br /> /d 4 <br /> WMs4- <br /> y <br /> l8,` . <br /> Note: The application cannot be considered for filing until all of the above questions are answered and the fee paid. <br /> Do riot write in space below- FOR DEPARTMENT USE ONLY�yZ7 3 if(off i6 <br /> Date of Application �"�``s� 7S Fees Paid State /- County 2-0 - <br /> Permit Issued/Rejected (date) -c?-5-- 7,5- <br /> Inspection Yes No Date <br /> Issuing Agent Name t! cif '4 l Valid No. Date Rec'd. <br /> , <br /> DIVISION OF HEALTH,P.O. BOX 309, MADISON,WI. 53701 - REVISED 3-1-74 <br />