HomeMy WebLinkAbout0268 MAIN STREET (CENT.) - Health (3) ' -{ cc$, CeAtCrU r Ile
i
. APB �
, ` IPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS
LOCATION NCR { Wyk) 8J !� C2J�S •-r yk NO. 9q
VILLAGE DATE 3,Z`
APPLICANT C� FEE
ADDRESS lam.: ' TELEPHONE NO. (Non-refUndablc
ENGINEER `-t C- TELEPHONE N0. - )�
DATE, SCHEDULED 3-
(Applicant's signature)
• • • • • � • e e o 0 o e • e •ie o n e e e e e o • • • e e o • e e e • • • • • • e • • • • • • • • • • • • s O I e • • • • • • • e • e • • • e O • s • • • •
1�SSfiSSOR'S biAP � LOT NU:
SOIL LOG S
SUB-DIVISION NAME T- 14S DATE J7 F 6 5' TIME (�
EXPANSION AREA: YES ENO r ` � ENGIN_EER:'N*
TOWN WATER /--PRIVATE WELL ���✓� � BOARD OF HEAL?
EXCAVATOR
SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and
percolation tests, locate wetlands in proximity to test holes)
f NOTES:
P
P
PERCOLATION RATE'• Z -�.►
TEST HOLE NO: �• ELEVATIO TEST HOLE NO: Z_ ELEVATION:
S 2 2
3 3
4 4 _
5 g
8 8
9 9
10 10-
11 . 11
12 12
13 � . 13
14
14 )
15 15
16 16
SUITABLE FOR SUB-SURFACE SEWAGE: . LEACHING FIELD_ LEACHING PITS L
LEACHING TREN:CHES��_
UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS:
NOTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED .ON PERC TEST APPLICATION
• ORIGINAL: COMPLETED IN ENTIRETY BY P . AND RETURNED TO BOARD OF HEALTH
COPY: RETAINED BY APPLICANT