HomeMy WebLinkAbout0121 RUDDER ROAD - Health (2) i . '
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APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS
LOCATION Gam, Z _ NO.
VILLAGE L DATE45
APPLICANT FEE /",b�
ADDRESS TELEPHONE NO. (Non-refundable)
ENGINEER jj� 4Z TELE ON `f c..
DATE SCHEDULED ��"-� ��..�- L•y X �
»+ / r` — - -
( plic.aa3 s sig ture')
• • •• • • • • o 0 0 0 0 • o • o 0 0 0 0 • e o o • •.• o 0 0 • o 0 0 • • • • • • o • • • o • • • o • • • • o 0 0 0 • • i•�•`•'i o'•'o • • • o o'i o'• • • • • .
ASSESSOR'S MAP di LOT NO:
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� �e�A SOIL LOG
SUB-DIVISION NAME DATE "`� � �, TIME ll.ZrZ5
EXPANSION AREA: YES NO _ Ra1y 6?bILLAC' , PS _ENGINEER
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TOWN WATER $/PRIVATE WELL BOARD OF HEALTH
/v/i4GDl�!Bls�i� EXCAVATOR
SKETCH: .
SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and
percolation tests, locate wetlands in proximity to test holes)
C9 NOTES:
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PERCOLATION RATE:
TEST HOLE NO: 1 ELEVATION: /9.S' TEST HOLE NO: ELEVATION:
1 e c'}yew a' 1
cr c,,.y er- .1,4way to�--+
2 L Pir- /O yr S/6 „ 2
3 Cl 14ye" Zfry 4/6 3
5 �qwo ray 5
6 C 2 14ye.r Z.Sy 4/6 6
8 8
9 - 9 •
10 10
11 11
12 na W4'k"--a/ q12
13 f�8 13
14 14
15 15 '
16 16
SUITABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD P LEACHING PITS__
LEACHING TRENCHES
UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS:
NOTE: ENGINEE'RING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICAT
ION
ORIGINAL: COMPLETED IN ENTIRETY BY P. E. AND RETURNED TO BOARD OF HEALTH
COPY: RETAINED BY APPLICANT
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