HomeMy WebLinkAbout0445 AMES WAY - Health (2)r �y �,-� w ,� � ; �
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/�I�AP.PLICATIO`,NFOR PERCOLATION TEST AND OBSERVATION PITS V
LOCATION_ l 7 A N M Yt/ + � NO.
VILLAGE_ DATES
APPLICANT /yf:13
k,ADDRESS ' TELEPHONE NO. (Non-refUndablE
ENGINEER _TELEPHONE
DATE. SCHEDULED_
AA
M no Qu_ (Applicant's signature:)
• • • • • • • O O O O O O • O •.O O A O O • • O O • • • e O e • e e e • • • • • • O • • • O • • • • • • • • O O I O • • • • • • • O • O • � • O O • O • • • •
ASSESSOR'S b1AP OT NU:
SOIL LOG
SUB-DIVISION NAME DATE TIME !-�l�
EXPANSION A7PRIVATE
YES NO �aX`Ti�2 y(� lade ENGINEER: R' '
TOWN WATER WELLJj B y
OARD OF HEAL?
11Sf e� Ex, EXCAVATOR
SKETCH: (Street name,etc• ,dimensions of lot, exact location of test holes and
percolation tests, locate wetlands in proximity to test holes)
GL-,'> %�- -- �� NOTES:
<74
I
i
( 6' - 1
tl
i (O
t
0
PERCOLATION RAT I,_ I f'I IJ f�► U� C s
TEST HOLE NO: ELEVATION: TEST HOLE NO: ELEVATION:
1 1
2S 2
3 ian S444-0 3
4 somw 4
5 5
6 6
8 YwvfJ• 8
g SAS 9
10 10
11 11
12 12
13 . 13
14 14
15 15
16 ' : 16
SUITABLE FOR SUB-SURFACE SEWAGE: . LEACHING FIELD -,, LEA ING PITS
LEACHING TREN:CHE§
` 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