HomeMy WebLinkAbout0041 ORCHARD ROAD - Health (3) clp1 0
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APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS
LOCATION � � _ NO. h- �
VILLAGE y% , gi p _ DATE 9"-- :143— '
APPLICANT -� -9iG L`� �/1 FEE Arri-0
ADDRESS TELEPHONE NO. (Non-refundable)
ENGINEER _TELEPHONE NO.
DATE SCHEDULED
(Applicant' s signature)
• • •• • • • o 0 0 0 0 0 • o • o 0 0 0 0 • • o o • •.• e o o • o 0 0 • • • • • • o • • • o • • • o • • • • o 0 0 0 • • • • • s • o • o • • • o o • o • • • • • •
ASSESSOR'S MIAP Si LOT NO:
SOIL LOG
SUB-DIVISION NAME DATE 3 L_ 7 � .—�� TIME
EXPANSION ARE YES N0� ,�• `,.C�1�(,e - C0.u��. _ENGINEER :1•1:
TOWN WATER PRIVATE WELL •E. 60.er! BOARD OF HEALTH
• (o P.)Mr EXCAVATOR
SKETCH: (Street name,etc_. ,dimensions of lot, exact location of test holes and
percolation tests, locate wetlands in proximity to test holes)
NOTES:
•
PERCOLATION RATE:
TEST HOLE NO: ELEVATION: TEST HOLE NO: ELEVATION:
1 I
Loam v+nA p. 1
2 — 2
4 �ubiL 4 -
5 .-- - 5
6 6
7 Coars e 7
8 San 8
9 �5 9
10
12 12
13 13
14 14
15 15
16 16
SUITABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD LEACHING PITS
LEACHING TRENCHES
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