HomeMy WebLinkAbout0082 NYE ROAD - Health (3) �a P��e I�Gc�, �'2vi}�1� ille
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APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS
LOCATION __dqLs- . VlA NO. ,�j
VILLAGE C' 7JT' 1ViC L� DATE ��
APPLICANT 91 Savv►�t,Z� FEE 1 � •�
\!ADDRESS ' TELEPHONE NO. (Non-refUndablc
ENGINEER _TELEPHONE NO• ' 2?'"' �
DATE. SCHEDULED �
MAP ��� G� ��,' (Applicant's signature)
• • • • • • • e o e e e • • e e� e e e e • e o • • • o e e • e o e • • • • • • e • • • • • • • • • • • • e e I e • •
ASSfiSSOR'S biAP ���.OTNU: " • • ' ° ' ° ° • • ° ° • ° • • • • •
SOIL LOG
SUB-DIVISION NAME DATE_
EXPANSION AREAS YES NO _ ��� j j l�y�' I�dC� ENGINEER:'?�� '
TOWN WATER PRIVATE WELL QD `tom 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:
Ag o
r
CIO
`0
1
I r
PERCOLATION RATE 1 'I1.J 2�t bf� ok
TEST HOLE NO: ELEVATION: TEST HOLE NO: ELEVATION:
• 1 1
' 2S
2
3 3
4 ,37 4
5 g
6 6
8 �l 8
9 S 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
SUITABLE FOR SUB-SURFACE SEWAGE: . LEACHING FIELD_ EAC 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 REmURNED TO BOARD OF HEALTH
' COPY: RETAINED BY APPLICANT