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AI'I'LICA` I N FOR PERCOLATION TEST A14D 011SER A`ZION PI'1
LOCATION/cL. ____----Nn.� w �`-
'
VILLAGE f_L3 � ,,� �f DATE
APPLICANTlIL � FEE� �'�-lam
ADDRESS TELEPHONE NO. (Non-refundable)
ENGINEER _ Gi 6s' ��;?� 17f TELEPHONE NO.—
DATE SCHEDULED °'",�.� s _
(Applicant' s signature)
• • •• • • • • o 0 0 0 0 • 0 • 0 0 0 0 0 • n 0 0 • o o O • a • • �-g• • • o e • • o e • • • 0 0 0 0 • • • • • • • 0 • O • • • 0 0 • 0 • • • • •
ASSESSOR'S MAP & LOT NO: �D/ 0�7q ��IP LOG_
SUB-DIVISION NAME^ S_ T czjjaj.••Q //DATE_ ��' •� '� TTME /���
EXPANSION AREA: YES NO /Y' �G .5. lG ENGINEER
TOWN WATER_LPRIVATE WELL .___. BOARD OF HEALTH
EXCAVATOR
SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and
percolation tests, locate wetlands in proximity to test holes )
NOTES:
&32 N r
I
PERCOLATION RATE: z Z M
TEST HOLE NO: .��� ELEVATION: T/EST HOLE NO;,_ ELEVATION:
2 4- - 2� /k -` ,�j Zr..L' { 5 �9 5 W� -
6 --- 6
10 IZo 1 0
11 -�
12 12
13 _ 13
14 14 �
15 15
A/o CCz/ �/L
16 16
SUITA13I.E FOR SUB--SURFACE SEWAGE: LEACHING FIFILA_�,I:AGHxNG PI`1'S_�
LEACHING TRENCHES_
UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS:
NOTE: ENGINEERING PLANS MUST SHOW 191RIBER ASS_TGNED ON PERC `.I'IaST APPLICATION
ORIGINAL: COMPLETED IN ENTIRETY BY P. E. AND, RETURNED TO BOARD OE' HEALTH
COPY: RETAINED BY APPLICANT