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i f <br /> ADDRESS OR LOCATION: !00(,1APN: <br /> OWNER: I� � ! � l +�c�i ��� c� DATE: ` �S <br /> APPLICATION #: DEPTH TO FIRST WATER: ft SOIL TYPE: <br /> REMARKS: �� ' 46 <br /> /6W_ LOCATION OF TEST HQLI Q$ (i t�lry�11Y �" + . TRU CTU RES <br /> I'I'll Illj9E TAL_ <br /> 9 04 FAJ 1 1I <br /> L i � S { � 1 � ; i i f t I i E � i [ i t • S +fl+. <br /> Vol <br /> I I i i i � i I i i I i ! I € ? i i `: 1 i ' ? � + I •i ! ! <br /> SOIL PROFILE (IF REQUIRED) <br /> Depth Soil Type Depth Soil T e Depth Soil T eDe th Soil Type Depth Soil Type <br /> TEST HOLE#1 DIAMETER: in DEPTH: 3%$_e in TEST HOLE#2 DIAMETER:__in DEPTHAR ," in <br /> `NATER `PATER <br /> TIME READING DROP REFILLED TIME READING DROP REFILLED <br /> .3S 31 <br /> l0 .l05 r 6� � Ll / 3 , U /0r p✓ �(7� rs� /i �3 <br /> in <br /> f <br /> y,i o <br /> aq3 3> 11 p,, ,oto -/ 00 <br /> ' <br /> ca— q0 3, ray <br /> PERCOLATION ATE: min/in PERCOLATION RATE: min/in <br /> RECOMITENDED SEP C AREA: RECONL TENDED SEPTIC AREA: <br /> 1 <br /> TEST PERFORMED BY: Phone: Date <br /> TEST CERTIFIED B Phone: — Date <br /> OBSERVED BY(RENS): / Phone Date Sf5 -+ S <br /> EHD 42-02-003 FERC TEST RATE FORIMIc <br /> REVISED 5/7/02 <br />