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^ . APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS
LOCATION !-AIL>r ISLE VVUOPS 33:A- 3 P�� ,�IZt�I!�3. � 9-� ��
VILLAGE_ NO.
APPLICANT `8Ullbij W DATE ' •'e �
tADDRESS FEE 407>,oa
' TELEPHONE NO. `7-71-lotAo (Non-reftxndabli
ENGINEER }�jGtL_ i E
TELEPHONE N0.
DATE.;`SCHEDULED --
2p�5���/ 11(( Rqiz]� 9 (Applicant' s signatur )
ASS ESSOR,SOijlkP j o\1[ LOT No C G • • • . . V • O O O . . . . . . p . . . y . . . . . . . . O O d0 . . . . . . . O . O . . .V 9 . ,
1,�� SOIL LOG
SUB-DIVISION NA14E l$(g YI!/pppS
EXPANSION ARL•'A: , YES ✓N DATE TIME ! �Z�
0 - ! yI�
TOWN WATER ✓PRIVATE WEL ENGINEER:'JQ'
BOARD OF HEAL?
EXCAVATOR
SKETCH: (Street name, etc. ,dimensions of lot, exact location of test hol
percolation tests, locate wetlands in es and
proximity to test holes)
NOTES:
' 3I � 31 • � , . .
i r SQ�
PERCOLATION RATE: fill �jVi/,)
LEST HOLE N0: ' ELEVATION:
2
l TEST HOLE N0: ELEVATION.
J.
.
3 .Sc� S@rcv 2
4 &1 s 3
5 4
6Y¢✓t,,Z,� 5
7 6
• 8 VIM S;WuSb 7
9 a
10 9
10
12
l3 12
14 . 13
14
15 15
•16
SUITABLE FOR SUB-SURFACE SEWAGE: . LEACHINGIFIELD
LEACHING -" E ING PITS v
CHESS
UNSUITABLE FOR .SUB-SUFACE SEWA TREN:
RGE. REASONS .
NOTE: .ENG•IN 32RING. PLANS 14UST SHOW NUMBER- ASSIGNED -ON PERC TEST APPLICATION
ORIGINAL': COMPLETED IN ENTIRETYp
COPY: RETAINED BY APPLICANT RNED TO BOARD OF HEALTH
. I •