HomeMy WebLinkAbout0218 PINE LANE EXTENSION - Health 1�� � O-K / 003
, J PPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS
LOCATION ,'%/_E:_ 4 �AJAJ N0.
VILLAGE
DATE
APPLICANT FEE
ADDRESS
TELEPHONE N0. (Non-refundable
, _ 0
ENGINEER �� �'Z TELEPH
DATE SCHEDULED �
App icant s signature
• • • • • • • • e • e e O • O • O O O o OO • O O • • • o e o • O O O • • • • • • O • • • • • • 0 • • • • • O e • e • • i • • • • • • • • • • O • • • • • • • • •
ASSESSOR'S m & LOT NO: ll� �Sr SOIL LOG /
SUB-DIVISION NAME DATE L '� TIME� �
EXPANSION AREA: S ��<<��7�Z. ENGINEER
TOWN WATER PRIVATE WELL - 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:
oa
At
x
r
1 ,
i
PERCOLATION RATE:
TEST HOLE NO: J ELEVATION: . TEST HOLE NO:Z— ELEVATION:
1 f} of
2 � � A 2 �.
3 41 3
4 4 -
5 5
6 _ /Z y 6 Xy y
7 7 /W
9 /t,jF,a a 9
10 10
11 11
12 v ' 12
13 13
14
� • 14 ,
15 15
16 16
SUITABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD LEA C G 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