HomeMy WebLinkAbout0152 LAKEVIEW DRIVE - Health (3) /Sa (Ltkel/1tuj aiVe ,
CeA+ON i I I e-,
46 APPLIC I N FOR PERCOLATION TEST AND OBSERVATION:VNO
LOCATION _ .
VILLAGE 9 DATE 46 j4��71 �-S✓
APPLICANT FEE
ADDRESS TELEPHONE NO. (Non-refundable)
ENGINEER _TELEPHONE NO.
DATE SCHEDULED m /�
0 Q (Applicant' s signature)
O O . O O O . O • O e O � �G . C G G . . .Ae C . . . . . . . u . . . . G G C C . . . . . . . C . O . . .,G G . C . . . . .
ASSESSOR'S hiAP LOTJO: ,�®(��-o
IL LOG
SUB-DIVISION NAME DATE ��a' '� �TIME
EXPANSION AREA: YES�NO� • O V4 ENGINEER: );
TOWN WATER PRIVATE WELL , BOARD OF HEALTH
i EXCAVATOR
SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and
percolation test -r -lloc tie wetlands in proximity to test holes)
NOTES:
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SO
`F
8 b
CP
PERCOLATION RATE: Z M r"�""\ -I2 '- N �- LA��
w e t__
TEST DOLE NO: „ ELEVATION: •0 TEST HOLE NO: ELEVATION.
`+1
-'t A, .,-t 2 4LcTw--
20 1v1ffR F/S' 3 �-zo Lc
�/7;3�4 C. zo 2� Z,9Y6� ���1 K��n�S 4 2m_Z4; IM,,Q�^..
5 Z y Z Z,5Y(/j � 5""� 5 24�_�Z L
�J65 6 �2_ � 't.517/Li 6?RAUe(' Pid 11 6 4Z-$`�
57.0 — 7 7 C 4
8 g
9 9
10 10 UJA-tt 2
12
11 11 g,,n,��.,..�•-�
12 13 of
13
14 14 JA
15 15 Clyl_
16 16 No,W79;
SUITABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD LEACHING PITS �1
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