HomeMy WebLinkAbout0253 FIFTH AVENUE (HYANNIS) - Health (2) T�l Nen o Na
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APPLICATION FOR PERCOLATION TEST AND OBSERVATIION PITS
LOCATION Z5 5 " /267 �LO,12
17 Ltd OPy O NO.� °�.�� zli
T VILLAGE DATE // /3
Up�� l°-FYf1-n�l�i��� _
APPLICANT. FEE
ADDRESS &IoZ ,�!C�,..Y�•��"�7 � �Ul //c /_T_TELEPHONE NO��— (Non-refundable)
ENGINEER WSLA.,e c AS qC TELEPHONE NO.362'?13
DATE SCHEDULED l�
/{](//y Apple t' s signature)
AES. OSb Oi AO P OCz. OL.O OT O ON OO.: O . . . . O O'O �O . . • . O . . . . . . . . . .. . . . . . . . . . . . . . G . O . . . O G . C . . . . . .
<t&v SOIL LOG
SUB-DIVISION NAME DATE I f gS TIME
EXPANSION AREA: YES N0� _ LA➢�' c As�;3C _ENGINEER )
TOWN WATER/PRIVATE WELL � � BOARD OF HEALTH
,-1 T_� _EXCAVATOR
SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and
percolation tests, locate wetlands in proximity to test holes)
NOTES:
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PERCOLATION RATE:
TEST HOLE NO: LEVATION:rZ, TEST HOLE NO: ELEVATION:
ZZ
1 1
a �� 2
3
4 4
S6 ti 5
6 _ 6
8
8
9 9
10 "Ce4z, Ste 10
11 z•�v c� 11
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_ BOA_RD_OF.HEALTH
COPY: RETAINED BY APPLICANT
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