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HomeMy WebLinkAbout0055 AMES WAY - Health (2) � ce�Mle-;'(02 ifl Ig� � oa�/ cal- /- - -- - - - APPLIJCATION FOR PERCOLATION TEST AND OBSERVATION PITS � LOCATION °� / r. (/� W - NO. P VILLAGE �//` _ DATE APPLICANT k�p—. b'e'i- 0 J 1,9 LAJ !� FEE `3 ADDRESS0 1 'Z_ Z- %MI) J' PHONE NO. G '1Iy on-refundable) ENGINEER____" 0IfT TELEPHO NO. DATE SCHEDULED_ (AP icant' s signature) . . . . O O O O O 0 . O . O O O O O . . O O-. . . 0 a 0 . O O . . . . . . 0 . . . 0 . . . 0 . . . . 0 0 0 O . . . . . 0 . O . 0 • . . 0 0 . 0 . . . . . . ASSESSOR'S MAP & LOT NO: f���(�OCD��O SOIL LOG SUB-DIVISION NAME DATE 17,h G eSS TIME EXPANSION AREA: YES ✓ NO _ G' Y` 4 ! gr t' ENGINEER l TOWN WATER /PRIVATE WELL TAMES C©,V4cF VBOA.RD OF HEALTH H�c/cev ,�s�Cet�q. C Si�"v 'y EXCAVATOR SKETCH: (Street 'name,etc. ,dimensions of lot, exact location of test holes and percolation tests, locate wetlands in proximity to test holes) NOTES: r Z o. 7S 1 r— fe IAIi.s Lor1 v� 4 43 I N 7ff 41 Tt! 2. 4 l man•PERCOLATION RATE: G TEST HOLE NO: 1 ELEVATION: TEST HOLE NO: �-- ELEVATION: O 1 � 11 �V��O. � �41 _To;;75.6 .sor 1 �� 2 �ne � �' �-• eS�t..� 3 �^L n - 4 4 v 5 S cx•-r L fi�5 2 6 TraCe-5 f 7 7 T/ dirt SL u 9 9 nn SQ z Cd �o. 11 11 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