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HomeMy WebLinkAbout0060 STONE HORSE ROAD - Health (2) � D C�me �S'e 12rA �, D��✓vi/le _ / � - u 'i ' APPLICATION FOR PERCOLATION TEST AND OBSERVATION PI N'.. �l �C fir— , 7 NO. [.00ATy4.. - ' y ,DATE 261 VILLAE I,FEE �•.. J= APPL ---� �CANTi '� (.11on-refundable, ADDRES.f � - TELEPHONE. NO. ENGINFE C�h = ('•./ ,.�i' -J /� H9�c y TELEPHONE N0. 7JS-uc, DATE SCHEDULED (Applicant' s signature . . • . .;4eoeoe, . e . eeoo • . . . • . . . . . . . . . . . . ... . . . . . . . . . . . . • . . . ..• • • • • . . . • . . . ... . • . . ... • • . ASSESS6OR'S t�i�P �.OT,NO: �q�/i4� i Sc, SOIL LOG SUB DX,VIS:ION NAME /6 ��(. DATE - "' - TIME 11, ;,XPAN3ION.AREA: YES ✓ NO _ J• l ��G �, ENGINEER . "TOWN WATER=PRIVATE WELL •7 +3���<< - BOARD OF HEALTE EXCAVATOR SKETCH:.' (Stree.t name,etc. ,dimensions of lot, exact location of test holes and ". percolation tests,' locate wetlands in proximity to, test holes) is + , NOTES: M , g�1p 1 1 1 Ali i Aya' 73 ootf t A ?ERCOI+Ax ,�T :RATE: VESTA N`.,,NO: ELEVATION: TEST HOLE NO: ELEVATION: 2 b 2 3 . 4 J d/vI 4 � 1 - 5'1 x 5 6 6 r:4 7- f 7 ' 9 9 1U. 10. ., 11 ,_ 11 i; 12 ,. , 12 r 13 13 1414 14 15 . 16 16 1UITAB�,,E FOR .SUB—SURFACE, SEWAGE: LEACHING FIELD LEACHING PITS LEACHING TRENCHES INSUITABLE FOR SUB—SURFACE SEWAGE. REASONS: TOTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION. . )RIGINAL COMPLETED N ENT RET Y P AND RETURNED TO BOARD,OF HEALTH :APY: r + '. RETAINED BY APPLICANT —