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APPLICATION FOR -PERCOLATION TEST AND OBSERVATION PITS ,
LOCATIONK �st.E. woo �2�
VILLAGE / �' No
- ✓ . N YAiJ IJ lS � 2V'l t.C�APPLICANT DATE
, vt�/SfDt=�V11 DIlJCt Co, �fJC �—
t,. FEE
\11DDRESS
ELEPHONE N0. (Non—reftxndabl
1 ' T '17l-�O�
ENGINEER z_ TELEPHONE N0. ' .
DATE;'.SCHEDULED -9�3/
-� �� (Applicants signature)
ASSLSSOR'S�bit�P� OT I�IOi . . . . . . o . . . . . . . A�:�� a'.`o . . . . . . . o s. . . . . . . . o . . . '. . . o . . . .
1�� SOIL LOG
SUB`-DIVISION- NA14E l Y!U S(� o0'DS
EXPANSION AREA: ;'YES ✓;NO
TOWN WATER ✓PRIVATE WELL ENGINEER;'?�'
BOARD OF HEAL?
�2t Sc,pc..t.•
8:EXCAVATOR
SICETCf3: (Street .name, etc. ,dimensions ,of lot, exact'"hocation of W,test holes an
percolation tests; locate wetlands in d
proximity to test holes)
NOTES:
g?
77
p 43W
'br2i v87
PERCOLATION RATE' 1`4IW—az�
TEST HOLE NO: S ELEVATION:
TEST HOLE N0: ELEVATION:
2 Z
�3Saicd 1
3 2
/I M 3
5 9A4 -
6 5
7 6
8 7
9 a
10 9
AeD 10
12
13. 12
13
14 14
15 .
16 15
.. LEACHING F IELD_ L' SUITABLE FOR;SUB-SURFACE SEWAGE: . 16 EAr
e/
ING PITS_
LEACHING TREN:CHE
UNSUITABLE FOR SUB=SURFACE SEWAGE. REASONS.
NOTE: ENgINEE�RING.r PLANS MUST SHOW NUMBER: ASSIGNED .ON PERC TEST AP
ORIGINAL': COMPLETED N ENT RE APPLICATION
P
COPY: RNED O BOARD OF HEALTH RETAINED BY APPLICANT