HomeMy WebLinkAbout0068 OLD FARM ROAD - Health (3) �O$ 6L� ern �-c�
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APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS
LOCATION_ NO. � i
VILLAGE '�" G /U/ DATE "
APPLICANT % FEE /l�fJ-G
ADDRESS TELEPHONE NO.4/3 967 sores-refundable)
ENGINEER _TELEPHONE NO. � ��
DATE SCHEDULED
(Applicant' s signature)
. . •• • • • o o o o o o • o • o o 0 o o • • 0 0 • •.• 0 0 0 • 0 0 0 • . • • • • o • • • o • • • 0 • • • • 0 0 0 0 • • • • • e • o • o • • • o o • o • • • • • •
ASSESSOR'S MAP & LOT NO:
SOIL LOG
SUB-DIVISION NAME DATE
EXPANS ION .AREA: YES NO _ ,C,C - L /`i u hpi _ENGINEER
TOWN WATER )� PRIVATE WELL /l_ BOARD OF HEALTH
EXCAVATOR
SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and
percolation tests, locate wetlands in proximity to test holes)
NOTES:
TPI
'fP2� ,
W l l,l.. IZC�QV i 12 L fo - Co 5 �q,C MOVA L o HSE
l? 1A-SUk1"^ GL(Z h.tA-ram12i L i \
`rZ�NGI-I 1J JS Y/-\LLATIO N4 v
PERCOLATION RATE: Z M I N Zl N
TEST HOLE NO: ELEVATION: TEST HOLE NO: 2 LEVATION:
�i
a 2 r , — OIZCq (-O^m o24a t.oArK
3 s►L-T �A� sv�3S 3 ��LT Ld,A,r-� 5 vRsolLr
" 4
43 3`b s l trT�. sA rt I� 4 3
5 5
6 6 G2AuL--.L—
8
9 pi L-A-CAA aSrff SAW ll 9 M l D GOB,iz s
10 TZ s)LT 10 T12 s I LT-
i�0 04 �iN� GeAdC 11 10°/0 - Z.0'/o rINC-
11 To G" Cos Es- G►ZAvo- 1� 6 n CO faaLCS
12 „'g 12
13 12.5 r3GT r-Ao C-, W 13 13071 f-40 C--Q- Vj
14 14
15 15 �tti'OF
16 16 ARNE 1H yG
SUITABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD_LEACHING, P _Or1+1LA
LEACHING TRENCHES v1 VIL
UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS: D
AL
NOTE: ENGINEEIRING 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