HomeMy WebLinkAbout0034 NYE ROAD - Health (3) � C9� DIO'C�0(o
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APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS tlel'
LOCATION �I NO. Pf `'� �
VILLAGE DATE '�"�
APPLICANT Vv\X'..i_
FEE_ - }
\IADDRESS TELEPHONE NO. (Non-reftindabIf
ENGINEE _TELEPHONE N0. ��e--; 3./7
DATE. SCHEDULED
KAW [cam j�...� (Applicant's signature)
• . • •ASSfi S•O e R SbA e4;LO• nT e N U.: o • • • e e o • e e • • • • • o • • • • • • • • • • • e o • • • • • • • e • • • • q
SOIL LOG
SUB-DIVISION NAME _ DATE TIME /A`
EXPANSION AREA: YES NO `
.] mc tom. (�la�y INC ENGIN_EER*
TOWN WATER z/ PRIVATE WELL fip ` 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)
NOTES:
fw
r
;. (40 4-7
PERCOLATION RATE': 1I IQ IM,14 04, cd%
TEST HOLE NO: `, ELEVATION: TEST HOLE NO: ELEVATION:
1 1z 1
F:_ ]
3 3
4 Sower Swinw STcAkT 4 _
5 5
6 ^ 6
8MOD
g '
10 � 10
11 11
12 12
13 13
14 14
15 15
16 16
SUITABLE FOR SUB SURFACE SEWAGE: . LEACHING FIELD_ EACH G 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 . F ANn RETURNED TO BOARD OF HEALTH
. COPY: RETAINED BY APPLICANT