HomeMy WebLinkAbout0050 FERNDOC STREET - Health (3) SD �erndoc S-Nu-i- Fh1� nn�s
(APPLICATION FOR PERCOLATION TEST AND OBSERVATION PI1T�S�I�y L/
LOCATION NO., --s ��1�j
VILLAGE / , DATE �.,�• �- �J
APPLICANT �i1/lG�/�Nh D e15 FEE_s = _
ADDRESS a ��'� f}iPrt;S'�o�eS ggANiJ►s OZ - / TELEPHONE NO. (Non—refundable)
ENGINEER _TELEPHONE NO.
DATE SCHEDULED
(Applicant' s signature)
. . .. . . . . 00000 . o . o . . 00 . . 00 . ... 000.. 000 . . . . . . o . . . o . . . o . . . . 0000 . . . . . . . o . o . . . o . . o .'. . . . .
ASSESSOR'S MAP 6* LOT NO: SOIL LOG
SUB—DIVISION NAME DATE_ � '' ,�, TIME ,� -
EXPANSION AREA: YES NO Q _ENGINEER
TOWN WATER r PRIVATE WELL EIJrRQ� BOARD OF HEALTH
ti biRt _C0A1,R✓G�0111 EXCAVATOR
SKETCH:: (Street name, etc. ,dimensions of lot, exact location of test holes and
percolation tests, locate wetlands in proximity to test holes)
NOTES: 5
011 Lfk�
3,1
lie
OAJ
O �DwE[LbJ�
o
�z
33 o'4-
PERCOLATION RATE:
TEST HOLE NO: � ELEVATION: 58•7 TEST HOLE NO: 0 Z ELEVATION: 99.6
1 1 TOP SOIL
3 3
4 6,ekvdly 4 -
�Ek G 5 &ARSE 5
6 so1 6 -A�,/le 6 kO
7 7
8 -
9
10 S/,*j d 10 q�_b
11 11
12 12
13 Co A 13
14 5 � 14
15 15
-7 16 6°TT M ,vo � R 16 /
SUITABLE FOR SUB—SURFACE SEWAGE: LEACHING FIELD LEACHING PITS_✓_
LEACHING TREN:CHES_V
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