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APPLICATION F OR PERCOOLATION TES
T AND 'btB�SERVATION PITS
LOCATION K �SCP. VVf70P5 4-0T' e4>�"r/1 V► tm N � (
VILLAGE_ O° y
DATE
APPLICANT 5 `f�Vllblkl . (A, f u0
\ADDRESS FEE 1 -e-Zj
' TELEPHONE N0. 171-/0(�o (Non-reftindable
ENGINEER E3 C. TELEPHONE N0. �78-9/31
DATE SCHEDULED '
oZ/LQ�l (APPlicant' s signatureSO O0 • O •' O n e O e • O O • • • O O O • OOO • O • • ♦ • • • • ♦ O O I• • • • • • • • O • O • • • O O • -O • ♦ • • 1
tISSESSOft'S biAP,& OT NU:
SOIL LOG
SUB-DIVISION NA14E ISM WOD-DS DATE
E?'CPANSION ARtA: .;YES ✓.:NO TIriE ����
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TOWN WATER ✓PRIVATE WELL ENGINEER: ��'' . .`r --
BOARD OF HEAL7.
BSc, ..1 1. ,EXCAVATOR
,
SKETCH: (Street .name;etc. ,dimensions of lot, exact '.'location of ��tes
percolation tests, locate wetlands in t holes and . . `
proximity to . est holes)
• NOTES:
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PERCOLATION RATE: A 14 `ZM IiA ; ✓WL Lass
TEST. HOLE NO: ELEVATION:
TEST HOLE NO: ELEVATION:
2
3 2
4 M�, 3
5 4
6 6
7 7.
g10
a
10
12
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12
1.3,
F
. 13
14
15
ti. .16. ,
SUITABLE 'FOR .SUB-SURFACE SEWAGE: LEACHINGIFIELD LEA
LEACHIN ING PITS
G TRENCHES_
;UNSUITABLE FOR:-.SUB-SURFACE SEWAGE. REASONS:
f10TS ENG,INEE�RING, PLANS 14UST SHOW NUMBER- ASSIGNED -ON PERC TEST PPL----
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ORIGINAL*:` C014PLETED N ENTIRETY APPLICATION
P RNED TO BOARD OF HEALTH
CQPY:' s RETAINED BY APPLICANT