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I�SCo�0(91� I002—
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APPLICATION F R PERCOlLATION TEST AND OBSERVATION PITS
LOCATIOTI S� /,� � NO 7 37
VILLAGE �� ) ( C DATE jy �
APPLICANT 5- L 9cs v I'-17LX5 FEE
kADDRESS TELEPHONE NO. (Non-refUndablc
ENGINEER I XZ $ �}�f )/�G J _TELEPHONE NO. �{ ng
DATE. SCHEDULED `7S
(Applicant's signature
ASUg66AVAAFSi.LOT W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . as. . . . . . . . . . . .
SOIL LOG
SUB-DIVISION NAME �Z
Q Arm G DATE TIME �
EXPANSION AREA: YES !--�O _ - '��� ENGINE RR: ' '_ E .�
TOWN WATER L PRI,VATE WELL _ J4:ayv"w-t_ vii 1441 kic BOARD OF° HEAL?
I EXCAVATOR
SKETCH: (Street name, etc. ,dimensions of lot, exact location of test holes and
percolation tests, locate wetlands in proximity to test holes)
L6U NOTES:
e ` ,
06?
F-7
PERCOLATION RATE
TEST HOLE NO: , ELEVATION: TEST HOLE NO: ELEVATION: '
1 $ 4,t 1
3 2 5u�
R -► 3
4 4 - I
' S 5
64%
t,W',.,JA ..
9 9
10 10
11 11 J
12 12
13 13
~_
14 rr 14v W
15 �e i cc��e✓- 15
16 16 -
SUITABLE FOR SUB-SURFACE SEWAGE: . LEACHING FIELD CACHING PITS �f
LEACHING TREN:CHE§
UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS:
NOTE: ENGINEERING PLANS MUST SHOW NUMBER—ASSIGNED—ON PERC TEST APPLICATION
• ORIGINAL: COMPLETED IN ENTIRETY BY P aron RETURNED TO BOARD OF HEALTH
COPY: RETAINED BY APPLICARETURNED