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Home My WebLink About0063 ELIJAH CHILDS LANE - Health 63 Elijah Childs`Lane Centery 116'. M c r r , A- 171 = 73. i i UPC 12543 �o No._53LOR HASTINGS. MN µlb I�-I -ate i l APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS LOCATION/4422�.¢,q 1U1'U11QL11__ 9S (�, �1� .�J//GLE NO. F`4z VILLAGE C�,(d�-E�/J/�L _ DATE APPLICANT 4�¢ jC, FEE r ADDRESS P /jVc� /A E�! ��0��L, TELEPHONE NO. 6-2,07�(Non-refundable) ENGINEER��(TE,p �r 1tJC ��+ PF TELEPHONE NO.I.Z� _9/' DATE SCHEDULED / -2---2-3 p C Azy� Ale, (Applicant' s signature) SOIL LOG SUB-DIVISION NAME ,jj7%E?jJ/LLE /�r/�i /ftj)B DATE_ /-2- 3� eO TIME =� EXPANSION AREA: YES ENO �(_E�� ,(�/E Z�JV&Er&ENGINEER TOWN WATER t/PRIVATE WELL Pe- BOARD OF HEALTH L A!/GG� EXCAVATOR SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and 4 percolation tests, locate wetlands in proximity to test holes) NOTES : I I d _15;013 � r4l a S ._ r n� `of �V� -f�:;L 1 J mA C'41 Lt)s LLA { P/ PERCOLATION RATE: / ZMrAJ 0< O>-Y TEST HOLE NO: - ELEVATION: TEST HOLE NO: ELEVATION: 2 - .�.a,�� 1 hoc, 2 3 3 ---4 ��-D• 4 - 5 7. � � 5 6 6 1 s s 9 9 10 10 11 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 BOARD OF HEALTH COPY: RETAINED BY APPLICANT LO CFl A y N U15 E /E W A G E PERMIT NO. V 1 l L A G'E -e n INSTA LLER'S NAME R ADDRESS o U e - _e o) , 1 n 0 Git�.ut ltl 1�� - h o. BUILDER 00 . OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED \� 1 (�3 I ij o NO...Y_L. f.....:: Fss........4'.Q........... OMMONWEALTH THE /"BOARD OF OFH EALTH Ts .............OF........ ......... e+f .� ApplirFation for Uhgp a al Works Ton' itrnrtuan ramit \ a Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syste a.A t No W D Ow, Address Installer Address Q Type of Building Size Lot.1� ....Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (,o )G Other—Type of Building No. of persons............................ Showers a YP g ---------------------------- P ( ) — Cafeteria ( ) Otherfixtures ------------------------------------------.............................................................. Design Flow....... .1.�.......................gallons per person per.day. Total daily flow.----..-_-. __..........._..gallons. WSeptic Tank—Liquid'capacity jl ..gallons Length................ Width................ Diameter...---...---.... Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.-..1r148.. Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date------........---------------........... Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.......---.--........--. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.......--............... x ......................................................... 0 Description of Soil..................................................................................................----------------------........--------•---------.............------•-- x w UNature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TTTIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be1en susu�ed�by th board of health. Sig .. ........"�°u�`, .................................... -. .. Date Application Approved By... .-• . ------- ---`.................................................................•- Date Application Disappro d r t e following reasons:.............................................................................................................. ...................................... ............................................................................................................................................ Date Permit No....SQ.`?r...... Issued•. ....... d- -..`)..•-. /............... Date 6 Fxs..........................._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...------ --.............................OF.......................................................................................... Allp iration for Bispnsal Works Tnnitrurtion Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .........................._.........----...--...........--- - - ------ .......................................... Location-Address or Lot No. ---••--•..............»......_.._............._....-•------........•---•---•-••••••-•-•--••-•--•• ..........__...................................................................................... Owner Address W r� ........................... ........... ........ Installer Address Type of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms.................................. _Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ................................................. Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid*capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch . Depth of Test Pit.................... Depth to ground water---__-:___-__•_--_----_. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ --------------------------------•----------------•---------------------............••--...-••_•••---......................................................... ODescription of Soil........................................................................................................................................................................ W U -•-••••••••••-•--••--•---•-•-•-••--•-•.................••-•-•-•-•--------------•-•--••-•--------•-•......---•----•--•---•--••••-•-••---•••--•-•----••-•••-•••-•-•-•---••----•-----•-.....--------•---•. W ............... ------------•...-•----•••---•••-•••••-••••-•--------•---•-•.....-------•--•---•-•-•-- ••••-•-•----------•--••----••--•-------••-•-•-•••-•••-...-••••-•--••-••---•-•--•---••-.._.._...... x U ,Mature of Repairs or Alterations—Answer when applicable............................................................................................... ............................... f greement: ' The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of I T lap. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. gned...................................................................................... Application Approve `,$y----•-- fDate Application DisapW'oddr the following reasons---------------------------------------------------------------------------------------•--•• -•---••••........•- •--•--------------------------- •--......__......--•-•------•----••--------•--------•........ ---------------------------------------------------------------------------- -------------- Date PermitNo.-�y-�........................................... Issued.......... ................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................0 F.... !S'' -j?:�'44.c............................................... . �rz�i�irtt#r laf f�unt��i�nrr ."` T S S T RTIFY, That the�ndividualoSewage Disposal System constructed (!�or Repaired ( ) r •---- ? by........::.... ... . ........ ............................................................. staller has been installed in accordance with the provisions of TI- r o The State Sanitary Code as described in the application for Disposal Works,Construction Permit No PP P T O."... dated_ /.-•••••-••--•-•-•-• THE ISSUANCE OF THIS CERTIFICATE SHALL'NOT BE CONSTRUE A GUARANTEE THAT THE SYSTEM WILL FUN //ION SATISFACTORY. DATE....IA_.._. _f... ............................................... Inspector-------- --••-••.. --------- Z........................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No � .............� .`...............OF...........: «frM� .`'...._.............. F � Did o a r Tnnstr ion rrnn# Permission is hereby granted.......................'.. __. - to Construct )t epa ) a In,' ual S age o atNo.'s• ---------`•--- -------------- ----------- ---•............ .................... .......................................----...-------- Street as shown on the application for Disposal Works Construction Permit No..... ..... Dated.........lv...... p, . .y...� ................................................. Y+.- 5 + t d DATE..... 7 j•••••-•••-••......•--•-••-••+--•--•-•_••--- Boar ealth FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS i " "+# ' SI•r1GLE �L1Mtl.�! - 3�31JviZ�OM� ;. j : bdt Lam{ FL oW n tic) 4 3 • 330 :(m.pv -�-� 33ov (So % • A15 66.RD. : USE- IOOd 64L. 14 �, o 2EA ISO- S.t^. A Sep � ISo SF '2.S • 3 7S G.P.Q. / �7Nf lc sox / T-57� 1, ,UGWALJ- A �'! 11 Q � i TpT'AL 'DE.SIGtJ =425 6..1?D. 472 TOTAL TOAILN FL.GW = 1 PMWCDLB.TIOLJ Wk, : t",Lj SMi Li�O¢ LLY,. � 1 Ap + ``N of 60, A. AL Tt`ST 52 �H� iin. 4''�iAb �• `/eI rye. . Lo Aal Ooe I c•oo IMr. s�»�oIL 40 ADS �fsr w✓. c„�. �. ' -Sox Ql•1. Seem (o _ M u1v. Ta.rtK SA W PtT r �7vcA✓dt... NC/t TLt ' ? is i .f" �` STOWS tJ' C��TII=IED 'PLC) PL./51,1 I_� --- - - EL= LOCATION GEaJTEZ,,/Ic.L 15 1-J o CAL b AT 1=` �J0 LVA•Ti5v - �- C-MRTIF-j 'rkAT THE Pt-AQ A1JD RL4PgE 0-EiJCC- W I7tl �1� IE.t_I�1E,P M01-1 GOMPLYS -T SETL7+AC oIC- C- -Tcw U Ot= 13 AZ► -r F LS pL. IL 34-S C G blES, ' REGlSTL2>=D 1.A1-tG SUZv�YoCS TI-415 FLAW IS UOT ZASCD V" Ia�J OSTEeV1L_►.G o ;/1rCAS�i. IWSt�tJMC!►J=' ��cliC�/G�{ T11L- Ui~�i�T�i SI�GWIa APPLI CAC "-r