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Home My WebLink About0050 NYE ROAD - Health (3) IIe- 1 �- APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS LOCATION_ � �� Qb NO. •� VILLAGE �- _ ( 1.(1��L uC�V ► DAT EM .-e P APPLICANT iQl'. o > Svcn/L _, FEE kADDRESS TELEPHONE NO. (Non-refUndabl( ENGINEER TELEPHONE NO. DATE, SCHEDULED_ MAP 14to Pus io-7 (Applicant' s signature) . . . . . . . . . . . . . . . .'. . � . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . es. . . . . . . . . . . .'. . . ., .e . . . . .ASSfiSSOR'S biAP 6'LOT NU: - SOIL LOG $UB-DIVISION NAME DATE TIME I/'`Z::P EXPANS ION AREA: YES NO �3 q t' }-I��a'�+�� ENGINEER''N' TOWN WATER %/PRI,VATE WELLD V3�rLM� BOARD OF HEAL? Lsco i e-- EXCAVATOR SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and percolation tests, locate wetlands in proximity to test holes) NOTES: 0 i iJ .. PERCOLATION RATE: 0(. ca3 TEST HOLE NO: ELEVATION: TEST HOLE NO: ELEVATION: 1 �S 1 2 3 PAW SAoo 2 3 4 S' -S tvuv- 4 _ 5 5 6 6 7 CL> 7 8 8 ' g tp° 9 10 10 11 11 12 12 13 13 14 14 is is 16 16 ` SUITABLE FOR SUB-SURFACE SEWAGE: . LEACHING FIELD^ , LEAC G PITS.A LEACHING TRENCHE§ 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 -'