HomeMy WebLinkAbout0071 BLOMIDON CIRCLE - Health IC) q
APPLICATION R PEROOLATION TEST AND •BSERVAT10N PITS
LOCATION L�U / NO. �`-•'� �7
VILLAGE G DATE �2
APPLICANT Z _ ^f FEE
ADDRESS ' �XV PHONE NO.
(Non-refundable)
ENGINEER•;2�-J L ` TELEPHONE NO.
DATE SCHEDULED
.............�! ..... ........./..1... 00 .. .............. Applicant's Signature).............................. .
..... .
ASSESSOR"S M P & LOT NO:
SOIL LOG /
SUB-DIVISION NAMEff DATE r � ! '' TIME
EXPANSION AREA:.YES D` NO ENGINEER
TOWN.WATER _ PRIVATE WELL - - L BOARD OF HEALTH
�i✓ GG7/ EXCAVATOR
SKETCH:• (Street name, etc., dimensions of lot,.exact location of test holes anal percolation tests,
locate wetlands in proximity to test holes)
\\ NOTES:
pn yob.
mo 3
Sf( 1
•, p•A�,9 ly u11
@Q \
� 9
)LATION RATE..
HOLE NO: `U ELEVATION: TEST HOLE NO: ELEVATION:
3.
�3 3 3
04 S c G 2S
L 7 6�
e V\A
o 10 10
11 l I 11
12 12 r
13 JA-1 E (C 13 J
14 14 /
15 15
16 16
'ABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELDpL LEACHING PITS K-
' LEACHING TRENCHES
-
IITABLE FOR SUB--SURFACE SEWAGE. REASONS: QJ
,. ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION
.;INAL: COMF•LBTED IN ENTIRETX 13Y P. E. AND RETURNED TO BOARD OF HEALTH
t; RETAINED BY APPLICANT �p