HomeMy WebLinkAbout0010 NYE ROAD - Health (3)FIC
i 1010100 L4
I��
V
APPLICATION FOR PERCOLAT N TEST AND OBSERVATION PITS ,/
' ]
LOCATION_ �tJ'i1n13 �(I.t� � i�l� �` ��fc NO. e
VILLAGE DATES
APPLICANT_ Ats`w 0 . SvwALX_, FEE
kADDRESS ' TELEPHONE N0. (Non-refUndablc
� .
ENGINEER_ INC, TELEPHONE NO._' ¢1,$°rsj
DATE: SCHEDULED_ a
AAI� 1� 1"BLS I� -G�- `{-10-5 TS (�� O (Applicant's signature)
• • • • • • • e o e e e o • e • O a .f e e e • e o • • • • e e • e e e • • • • • • e • • • • • • • • • • • • e O I e • • • • O • • e • e • • • e o • s • • • • o
ASSfiSSOR'S hiAP 6a LOT NU:
SOIL LOG
SUB-DIVISION NAME DATE � �` �-J�" TIME��- �
EXPANSION ARE YES NO ENGINEER.'N .
TOWN WATER PRIVATE WELL "D--�6AaU BOARD OF HEAL7
EXCAVATOR
SKETCH: (Street name, etc. ,dimensions of lot, exact location of test holes and
percolation tests, locate wetlands in proximity to test holes)
NOTES:
• � � .\ 13t�17\ i
. PERCOLATION RATE:_ 1104 IIM OL 6ss
TEST HOLE NO: ` ELEVATION: TEST HOLE NO: ELEVATION:
1 aw l
2 Sioi(1 2
3 3
4 4 _
• 5 LLAi:I 5
6 Mom , 6
8 S,A1 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16 /
SUITABLE FOR SUB-SURFACE SEWAGE: . LEACHING FIELD_ LEAC NG 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