HomeMy WebLinkAbout0010 REGATTA DRIVE - Health (2) IQ
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APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS ry
LOCATION /;� LAK.t✓-- � for 30 Mrrl�. �tt. N o. �� ��
VILLAGE_ +/ �yA�tJtJLS � ��-hV�tlrC� DATE_��✓��'��
APPLICANT SCDi='�(��LAIkP 'C.a' ��JL• FEE
I,ADDRESS ' TELEPHONE NO. "7 -10�4o (Non-refundable
ENGINEER_ [NIB ,�C_ _TELEPHONE N0.
DATE..SCHEDULED . �.--
(Applicant' s signature)
ASSESSOR'S Di
. o . a . , o . .LOT' . o .NU: a�a . . ., . . . . . . . . . o �1. . . . . as. . . . . . . . . . o . . . . . . o , . . . .
AP � .
,��j OIL LOG
SUB-DIVISION NAME I$( i[�C1pVS DATE TIriE
EXPANSION AREA: YES ✓ NOc Y� �
ENGINEER:'?�.
TOWN WATER ✓PRIVATE WELL E-b R-
BOARD OF HEAL?
EXCAVATOR
SKETCH: (Street name, etc. ,dimensions of lot, exact location
of Percolation tests, locate wetlands in proximity to test eholesst �es and
NOTES:
V1,0S
0•34 Ai_ /
LD
oCA
' so
PERCOLATION RATE•_� N,I
PEST HOLE N0: ELEVATION: TEST HOLE NO:
ELEVATION•
2 l
5v�so,� 2
3 2 3
4 4
5 S � 5
6 6
7
• 8 ��ciu>�I f3 .
9 9
10 10
11
12 Sn 1
13 2 13
� t
14 14
15 15
16
` SUITABLE FOR SUB-SURFACE SEWAGE: . LEACHINGIFIELD LE ING PITS
LEACHING TREN.CHE§
UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS:
ITOTE: ,ENG.INEE�RING PLANS MUST SHOW NUMBER- ASSIGNED .ON PERC TEST APPLICATION
ORIGINAL': COMPLETED IN ENTIRETX I3Y P . E AND RFTt1RNED TO BOARD OF HEALTH
COPY: RETAINED BY APPLICANT