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APPLICATION FOR" PERCOLATION TEST AND OBSERVATION PITS
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!~ VILLAGE C NO.
E�y t t.t Fs DATE 11'11,rP!
APPLICANT__j3Ag - UIlDI1J�
\1 DDRESS FEE,1SYfj� fry
TELEPHONE NO. 171-/Otto (Non-refi:ndablE
ENGINEER
TELEPHONE NQ. LFZ�-9/31
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DATE``S CHEDULED N--- ,_„ ------�
`APPlicant e s signature)ASSLSSOR'S�biRP�&` O�TNOi � � • • • " " '��` • • • • • • � • • •✓, • • • • . . . . , , d, . . . . . . . a .
SOIL LOG
SUB DIVISION'. NA,
21E
�S[� Y�oODS DATE
EXPANSION. AREA: 'YES %N01 .
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ENGINEER:'?Q'
TOWN. WATER ✓PRIVATE WELL —� L------------
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OARD OF H L7
SKETCH: f I �•. EXCAVATOR
( ercet `name etc. dimension lots exact location of '•test holes and
percolation tests, . locate wetlands in proximity to test holes?
NOTES :
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PERCOLATION RATE: ( I W I 012 N<F
'VEST HOLE NO: ELEVATION:
�- 1 TEST HOLENO:
Lo', 4- ELEVATION:
2 1
31i3Sot�.- 2
4 3
5 4 _
S tJ�y 5
8 7
U ,
9
10 9
10
12 -"
13 12
14 . � ., • 13
15 14
• •16 15
SUITABLE FOR SUB-SURFACE SEWAGE: . : LEACHING IFIELD_, LEA N
LEACHING TREN:CHESz G r ITS
UNSUITABLE FOR 'SUB .SURFACE SEWAGE. REASONS:
NOTE: ;ENG•INE2RING. PLANS 14UST SHOW NUMBER• ASSIGNED .ON PERC TEST APPLICATION
ORIGINAL': COMPLETED N ENTIRETY p
COPY: RETAINED BY APPLICANT RNED TO BOARD OF HEALTH