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ADDRESS DLC r PA # <br />APN <br />PERC TEST <br />DATE <br />(2>'O>i>`0i SU# <br />PARCEL Perc DEPTH PERC RATE <br />OR LOT # Hole # (feet) (min/inch) COMMENTS (PASS/FAIL) <br />DATE SAMPLED TYPE OF WELL NITRATE moll- DRCP im/1 FDR uo/L COMMENTS lother address for well samnledl <br />NITRATE LOADING <br />RESULT (mg/L - N) `'.- SR #: SR �O b �� 1 SR Date: <br />