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g('I APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS
ot NO. 2S
LOCATION �l[� DATE S
VILLAGE A.Al Gd
FEE,0
APPLICANT
TELEPHONE NO. (Non-refundab e
ADDRESS 3
TELEPHONE NO. ^
ENGINEER
DATE SCHEDULED ( plicant' s signature)
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• ASSESSOR'S btAP LOT NO: SOIL LOG 1�
MAPS zS3 RGti'L I3- i DATE 41 bk%;r, qC TIME /Z .IS
SUB-DIVISION NAME _� L- rs _ENGINEER !.
EXPANSION AREA: YES_XNO _ BOARD OF HEALTH
TOWN WATER-/PRIVATE WELL / G EXCAVATOR
SKETCH: (Street name,etc. ,dimensions of lot$iexact
locatiimtY n of testtest
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percolation tests, locate we NOTES:
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PERCOLATION RATE: �_! . T EVATION: .�
TEST HOLE NO: //( ELEVATION: TEST HOLE- 10:
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SUITABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD LE CHING PITS
LEACHING TRENCHES
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