HomeMy WebLinkAbout0130 ROSARY LANE - Health (2) r � k S ` _a n�t ♦ �M� s F r�� �
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APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS
NO 2,5
LOCATION , V
VILLAGE
DATE
APPLICANT FEE
ADDRESS ;� ;r = TELEPHONE NO.4zF' `o J�(Non-refundable
trite�_i� TELEPHONE N0. 7? -00� f
ENGINEER J . _ _
DATE SCHEDULED As
(Applicant's signature
• • • • •'� O O O O O O • O • O O O O O O • O O • • • O O O • O O O • • • • • • O • • • O • • • O • • • • O O O O • • • • • • • O• O • • • O O • O • • • • •
ASSESSOR'S MAP & LOT NO: > 4� SOIL LOG
SUB-DIVISION NAME / DATE Zf
EXPANSIQN 'AREA: YES NO _ 74. rL ENGINEER .
TOWN WATER PRIVATE WELL BOARD OF HEA. T
EXCAVATOR
SKET61j: (Street name,etc. ,dimensions of lot, exact location of test holes and
percolation tests, locate wetlands in proximity to test holes)
NOTES:
r
� 0
13 A
�It RV
k t.. ,
34 i
Y
PERCOLATION RATE:_
TEST HOLE NO: ELEVATION: TEST HOLE NO: ELEVATION:
2 2
3 3
5 C�A,z -i-o 5 - �,��► �
r�
6 M 5�� 6 l�►'t�A�vR�)
9 9
10 10
11 i 11
12 12
13 uo i-{=o 13
14 . 4
15 15
16 16
SUITABLE'•FOR SUB-SURFACE SEWAGE: LEACHING FIELD Li4eHING PITS
LEACHING TRENCHES
JNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS:
JOTD ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION
)RIGINAL: COMPLETED IN ENTIRETY BY P. E. AND RETURNED TO BOARD OF HEALTH
:OPY: . RETAINED BY APPLICANT