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APPLICATION FOR•, PERCOLATION TEST AND OBSERVATION PITS
LOCATION
VILLAGE DATE �� f'rs
APPLICANTa_ ,�':�Z s2, r FEE « �
ADDRESS TELEPHONE NO. (Non-refundable)
ENGINEER ,( / „� _TELEPHONE NO. ,7�,2 `-��Zll
DATE SCHEDULED—
(Applicant' s signature)
• . •. . . . . O O O O O . O . O . O O O . 9 O O . O Q Q�G O j• y�.� • . O . . . C-. . . G . . . . C C C C . . . . . . . C . O . . . V G . G .. . . . . ..
ASSESSOR'S MAP & LOT NO: ��� / /V�'S/�(/_/
SOIL LOG «� s�
SUB-DIVISION NAME ��2p DATE_ 6 ^��U " TIME l �
EXPANSION AREA: YES NO� 1� '�, G,� ENGINEER
(TOWN WATER / PRIVATE WELL �' BOARD OF HEALTH
EXCAVATOR
SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and
perco�iatiron tests, locate wetlands in proximity to test holes )
NOTES :
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PERCOLATION RATE:
TEST HOLE NO: ELEVATION: TEST HOLE N0: ELEVATION:
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r4t 4 4,
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8 _, 8
9 1
10 t32 2- 10
12 12
,13 _ 13
14 14 C
15 15 .
16 g0 _Wf 16
SUITABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD�_LEACHING PITS _
LEACHING TREN:CHES ,,4,
UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS:'
NOTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION
ORIGINAL: COMPLETED IN ENTIRETY BY P. E. AND RETURNED TO BOARD OF HEALTH
COPY: RETAINED BY APPLICANT