HomeMy WebLinkAbout0060 FIRE STATION ROAD - Health �n0 �tle. S �rn 12d., bSk
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APPLICATION FOR PERCOLATION
TEST AND OBSERVATION PITS
NO.
LOCATION
VILLAGE ��� ��� DATE'
ATE T
APPLICANPI !
FEE(Non-refundableADDRESS 6,�T�v/C Cam' TELEPHONE NOENGINEER �c -TELEPH I O.DATE SCH -s
(Applicant's signature 7`
. . . . . . . . . . o . o . . . 0000 , L LOG
ASSESSOR'S biAP & LOT NO: l,/
SUB-DIVISION NAME DATE TIME 1.;::5,��
EXPANSION AREA: YES NO � G = ENGINEER'?;
TOWN WATER r/PRIVATE WELL /2 BOARD OF HEALTH
EXCAVATOR
SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and
percolation tests, locate wetlands in proximity to test holes)
NOTES:
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C> AP,
- 4
PERCOLATION RATE:
TEST HOLE NO: ELEV TION: TEST HOLE NO: Z ELEVATION:
1 1 a
2 '� 3
4 �`
/ 5
6 _
7
, 4,0,04
9 9
12 12
13 13
14 14
15 15.
16 16` r
SUITABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD LEACgiING PITS
LEACHING TRENCHES
UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS:
NOTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION
ORIGINAL: COMPLETED IN ENTIRETY BY P. E. AND RETURNED TO BOARD OF HEALTH
COPY: RETAINED BY APPLICANT
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