HomeMy WebLinkAbout0045 AMES WAY - Health (2) 4s AM wa� , CeAterui III
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Y APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS
LOCATIO f-�� / �t ��;,� � &41 �U/ , N0. — 0
VILLAGE v t�-P//J`j / _ DATE
ii /� G 1 1 Z>
APPLICANT /A I0eh - 0 �� / FEE
ADDRESS y �9 /`J ► 5 TELEPHONE N0. �--- �T�n-refundable)
ENGINEER d TELEP E NO
DATE SCHEDULED
g bC�G��O 2- (A cant' s signature)
. O . O . . . . . . O . . . O . . . O . . . . O O O O . . . . . O . O . O . . . O O . O:. . . . . .
ASSESSORO'SO O MAPOOO� LOTOO O NOOO:O . O O O O
SOIL LOG
SUB-DIVISION NAME DATE / ZZI/ cs ® � TIME / O ® O
EXPANSION AREA: YES ✓NO _ 2a-rd 4T j �(2..-7 ` ENGINEER
TOWN WATER ►PRIVATE WELL C"Ar,no7 �; Chi,/Ld .v BOARD OF HEALTH
H/ cK E Y L'-,k EXCAVATOR
SKETCH: (Street 'name,etc. ,dimensions of lot, exact location of test holes and
percolation tests, locate wetlands in proximity to test holes ) .
G, NOTES : fosx- Z>
Z 7 bSz Te.
09'J t A 0 : 3 0 ./ / .,
1 AA �� r� . Oi✓ oT�� .
'J
7'ems Z /� v� e T
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PERCOLATION RATE: I►'1 �,� I �, ,
TEST HOLE NO: ELEVATION: TEST HOLE NO: ELEVATION:
2 2 - c�
3 � _ 3
4 4 -
�5 #.Z5
6 ✓e r-� •, e ?e .s`" �--, F C. 5 cc
�� i Z®'17
8 /� -!-"c o-, 8
co '`� 9 .S a.s oL 9 /Y) PJ
11 v� �l
12 12
13 13
14 14
15 15
16 16
SUITABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD LEACHING 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