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HomeMy WebLinkAbout0020 VAN GOGH DRIVE - Health 20 VAT A = 146105 t1 a TOWN OF BARNSTABLE_) LOCATION b SEWAGE'# VYLLAGE�S ASSESSOR'S MAP-& LOTMA INSTALLER'S NAME&PHONE NO. 1,*71%fi r . SEPTIC TANK CAPACITY . l d r U (ty ) f (size) LEACHING FACILITY: i NO.OF BEDROOMS BUILDER OR OWNER i PERMITDATE: / ® COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Faciliy(If any wetlands exist within 300 feet of leaching facility) Feet. . Furnished by f s .M r 3b- 3 a3 AL A �.< .. � • No. atC.�X% — © 7? Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Y PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprication for Migaal *pztem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon ) ❑Complete System ❑Individual Components Location Address or Lot No. _-2C9 CJ i ry 0C,-1eru Owner's Name,Address and Tel.No. Assessor's Map/Parcel %L 1 Y W H Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. SF e- C Type of Building: Dwelling No.of Bedrooms _Z1 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 5,23r 'di.L2 Type of S.A.S. �L�Cst ��'�`�_ L• Description of Soil S-WIVu/ Nature of Repairs or Alterations(Answer when applicable) ' -S'r < U Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has bee oaz f h. Signed Date Application Approved by Date Application Disapproved for theWIlowinV reasons Permit No. a,023 D �� Date Issued �s--=— -- -- -- — --—----- --- — ————— No. as el Fee r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: `,. Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS 01pprication for �Digpogal *p.5tem Construction Permit Application for a Permit to,Construct( )Repair( )Upgrade( )Abandon( ) El Complete System O Individual Components Location Address or Lot No'. ,?C2 ¢VlJ^C05�04i I e-r,,t t Owner's Name,Address and Tel.No. Assessors Map/Parcel ` 1 H G-\_,e,,/ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms :, Lot Size sq.ft. Garbage Grinder( ) Other Type of Building > No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 19-c-f 5-.-1.. (g-k(M-) Type of S.A.S. %A%L.�k Cat Pk ccf--) A� L-�L. Description of Soil l�h Sy+, JQ i Nature of Repairs or Alterations(Answer when applicable) t L{` Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenanci„e of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has beer isstaed-b}�•this.1oar G ` Signed w Date `/ Application Approved by Date Application Disapproved for the llowin reasons Permit No. /r-" Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded l✓1 Abandoned( )by , 1 at -CD q iA r{ tr-, r4 I�ST��yti� � has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. a- 3 9�2 dated Installer Designer The issuance of this permit s allh}of be cdnstrued as a guarantee that the system will function asf jdesigned'. /� r Date _l/ �� Inspector /� %� 1 �ih a➢ IO k��'i/ ----------------------------- ------ No. Fee !� _ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Di000ar *pgtem Con.5truction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( L-).AbarMon( ) System located at �. o v rptj.J -r•O 0 S-`I—,k- and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be complett^e��d}}within three years of the date of this permit. Date: _ A- �1 (1tJ Approved by �'� 1i6i99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. 4`F CERTMCATION OF SKETCH kYD :APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGN-ED PLANS) hereby ce:tiiy that the application for disposal works s constmaion permit signed by me dated (````0p concetnins the property located at -�>U V Pw & D,-,� meets all of the following criteria: . Ir The failed system is tonne-ed to a residential dwelling only. There are no co mme.c.al or business uses associated with the dwelling. `o• The soil is classified as CLASS I and the eercoladon rate is less than or e goal to nunutes per inch. �•/`I"nere are no we lands within 100 feet of the proposed septic srse n (/• There are no private wets within 1.0 fert of the proposed septic srsrem There is no in-ease in flow and/or change in use proposed . P There are no variances requested or needed_ The bottom of the proposed leaching facility•Hill not be located less than five feet above the ma.,amum adjusted groundwater table-levraucn. (Adjust the groundwater table using the Frimotor method when apolicablel the S.A.S. will be located with 2J0 feet of any vegetated wetlands, the bortom of the r000sed P . leaching facliry will not be located less than fourte:n(141) feet above the maximum adjusted groundwater table e!evaLon, Please complete the following: A) Tao of Ground Sur,"ace clevadon(using GIS informadan) B) G.W. Elevadan D =the M,�.:<. ;;igh G.bV. Adjus-Lrrteat D TTERE�i CE- BET IWEEN a.and 3 Z SIGNED : D a, (Sketch proposed plan of srp.em on baca). a:�=th raldcr :-t G PT TOWN OF BARNSTABLE: LOCATION b 4$ SEWAGE # �W VILLAGE2LI ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 11*71 Z3�/ �► S' f i �, SEPTIC TANK CAPACITY _mod d c) LEACHING FACILITY: (type) ,L7L /T ��+�'S' (size) NO. OF BEDROOMS BUILDER OR OWNER i PERMTTDATE: I COMPLIANCE DATE: l� Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by j . i - r�- ��' f CAT ION SEWAGE PERMIT NO. V LLAGE !; INSTA NAME 't& . DRESS , r f c It UILOE R OR OWNER n ® ATE PEItINIT I Ill0 DATE COMPLIANCE ISSUED l �_ ��-- �� �� '-- �.... \ �� .. .... G��� . Pz ^ ` � r��_��_��_____ � THE COMMONWEALTH ormAssAoHussrrs � ������ ���� ���� HEALTH � . �"�~""" ~�� =~" � "��. .~~ " " " �p--�-�~~ ---� ---+.'^^.---'~.'^_�~~--''-_'^---- ��� ^� � ����lira�on ��� ���a�� l ����ks ��ono�u�iD�� ��rrmit � ' . ' . � Application is hereby made for u Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: �� � --------- -T.C.;i.n A da da s s ......................---'__'---`_--_'-- - --_'--- -..... '__ .......'------'���"�--------'_--------'---. Owner ^ u -------------_�~.-� __-'���%�C���'���----- --------------'�����-------------- --......... ---------_ /"m"xer Amr e= Type of Building Size .� �� uGrinder (�feetfeetoe. ' Gur� �Dv �lioQ- No. of Bedroo � I � �� Other—Type of Building --.^ __ Bo. cf yec0000--.-------.-' Showers Cafeteria P4Other 6~^. -.----.-.-------_-_-.---_------- .------' ) � Design Flow.....................5',5'-..........gallons per person per day. Total daily flow.---_-3 J-�)..................gnDnoo. Septic Tank Liquid capacity1fPa0gallons Length................ Width................ Diameter................ Depth................ Disposal Trcucb--No .................... Width-------' Total Length.................... Total area....................sq. ft. > �� �� D���cc- D�� ��mv Total �� Z Other Distribution box (--jr- Dosing tank ( ) f '~~ Percolation Test Results Performed bv.........................�� -- /4,4-4-3- �� I� Nu per inch Dc�b � �� Dept ground water...... _ Test Pb No. 2-'.--.1.....-uiouteuycr inch Depth of Test f��-��------ Depth to ground water........................ O � ---'''--'.--- � ................ U Nature of Repairs nr Alterations—Answer when .-.-----.-....-------_.-__--_.._......_._______ --'----'-----------------------'----''-'---'-''----'-'---'--'''-------'-''--'--------- ^^greencot: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TL 1'i U 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 th!Aard of#h. Sned....0: ----------------------------- ...... - o=m ApplicationApproved By-- --................................................................. ........................................ Date Application Disapproved for the lowing reasons:................................................................................................................. -----'--''__-..__-'---_'...'-__--__-_.___------_-'_---__----_'-_._..----____-'._'-------- o .'. . . . DatePermit No Date No_ .................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................ ...................OF.................................................. Appliration for Biiipoiial Vork,5 ToniAr urtion Funit Application is hereby made for a Permit to Construct or, Repair an Individual Sew"age Disposal System at: ............................... .... Add....S............................ .. OA.... .........or..................................................... ................................. ......CQlq....... Jk.... .......( ik...................................................... Owner Addres-s.- .........P41'ac.0A......... ..................................................................... ............................... .............................. r Installer Add' Type of Building Size Address ---dtdTA....Sq. feet U Dwelling—No. of Bedrooms__....._. ------------------- ------— Expansion Attic (/j/ Gar age Grinder QUb - aOther—Type of Building ...... No. of persons............................ Showers Cafeteria < Other fixtures -------------------------------------- .................. ....... ................ flow:......... .: __. __..._. ........ -------*...........* person per day. Total daily " . .............gallons. Design Flow..................... . ..............gallons per 1:4 Septic Tank—Liquid capacityIP0.0gallons Length................ Width................ Diameter_____......._._. Depth......._....,_.. Disposal Trench—No..................... Width..............._._.. Total Length__........__._....._ Total leaching area. ...................sq. f t. > Seepage Pit No________________ Diameter.-____---__:._____-. Depth below inlet...::...._.____.____ Total leaching area.................sq. f t. Z Other Distribution box Dosing tank Percolation Test Results Performed by.......................... Date.........7. h 3 ...... .... ........Test Pit NO. 1_4� minutes per inch Depth of Test Pit........ .......... Dept to ground water........ -+ f, - ------------ 44 Test Pit No. 2......7.......minutes per inch Depth of Test Pit................... Depth to ground water........................ ...... .......................................................... Sail ................:................... r Cool 0 x Description of ---------------- ....... ............................................... 1 Lyn,...... U ..................................................................T..!Xz.. ....... .-J-- ---------------------------------------------- ........................................................................................................................................................................................................ U Nature 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 TITLE; 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 and of th. 7,S, ed....... . .. .. .......................................... ------ Date ApplicationApproved By.......... .................................................................................. ........................................ Date Application Disapproved for the lowing reasons:.............................................................................................................. ........................................................................................................................................................................................................ Date PermitNo.......................................................... Issued...................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........TA A ..X............OF................ ............................. (Intifiratr of Tompliatta THIS IS TO CERTIFY, That the Individua Sewage Di al System constructed or Repaired by..................................................... ................................................................................................. at......................................................... .........7_�.I_S(............... ...... .................... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated_.....-_._....._.......__...____................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE7 AS A GUARANTEE THAT THE SYSTEM WI kL IF CTION SATISFACTORY. ­__. DATE-- —----------------------------------------------------- Inspect ................................................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 'TO 44�� 0 F V.44&t.g No......................... ............... FEE........................ Raposal Works Ton.&Wwitnt Vkr ft Permission is hereby granted............................ I D . ... ........................................................... ..�_ _41A..).......... . to Construct or Repair an Individual Sewage Disposal System at No......................................................L�§ ­1....I------------VA. 4��..........Lta - . .........0 Street as shown on the application for Disposal Works Construction Permit No....__...._ ated.......................................... .......... ...... ............................................... ....... . ... .. DATE.-- .................................... ------------------- Board of Health FORM 1255 A. M. SULKIN, INC., BOSTON r � S r 3`1\- 34 ,a o - r�eaAy -.U 7— I- { M f S: 110 eOF 60 lf' lM ROB SE -" µ �o.10951 O ti lop' f / t� NAL a .�5 LEGEND EXISTING SPOT ELEVATION OxO� CERTIFIED PLOT PLAN . EXISTING CONTOUR --- p FINISHED SPOT ELEVATION` FINISHED .CONTOUR 0 APPROVED s HOARD OF HEALTH �C IN DATE AGENT SCALES )�- `�� DATE , %o r192 DEL DREDGE ENGINEERING CQ IN C�,I$NT 1 CERTIFY THAT H T THE PROPOSED EGISTERE REGISTERED JOI1 M0. g BUILDING SHOWN ON THIS PLAN CIVIL LAND CONFORMS TO THE ZONING LAWS E GINEER U pR,6r'--w- --- OF ®ARNSTA61lE, t'W'AS3,} 712 MAIN STREET. . CM.•.BY, Rpah / � , ,./A5 NYANNiS, MASS'. SHEET_L OF DOE REG. LAND SURVEYOR 20 FT. M/N NO !F E/TNER ?NESEPT/G.TAN/C OR LEAC/,i/iYG PIT AME MORP TNA/V I2"SELOPV r,} • A O vR E Al %II M R 24 O E R.E� N CONGR�TE , 4..PVC S/►A L L BF U ORAOE. AN P/PL BRO .FI'TRA yEAVY CAST IRON COVER Sh'ALL BE USED M/N. P/TCN v CORER'S Yappg,Q FT DR/VEWA Y ' — 2% MiN. G"ONCR�1O'TE CO ✓ER CLEAN .SANG. R - - - 2 -AYER 4"CAST IRON P/PE. t U c7 0 v o • Poo OF D. -3/8 f SEPTIC. TA)VX D/ST, o a, • • • .• • • • • • �. e + WASHPD S7t�NE BOX • I 8 • • • • • � .•oi ., , ♦ • • pEPTN • • t • ; pa A.ShIED ST40NE 2,5= s s • ' • • • • • . . • • Y7/ 7 K . • s • • • • • • • . • P !�1,ST SEEPAGE I AIVCA T CL EVA77DN S 07 DR • • • • • • EgLI/v /NYERT,AT O!J/LD/NG 3 9,0 FT..' 6 FT D/AM. INLET SEPTIC T.4/VK- 3B.S.. FT, /O FT. O/AM• CCsEETABUL.,4TION,, DUTLET SEPT/C TANK 3�.6 ,FT, /NL�T U/3TR/Bl/TOON BOX 38 q FT. SECT/QN OF GROuNO P1447-Elr TiIDLE OtJTLETDISTR/B4"VaNBAX 38 Z FT. ' /NtET LEACH/NG:o/T 3S.r9 FT SEJVAGE 014S,004AA. SYSTAFM LE�4CH//VG �!T IrAJUL�tT/DN SCALE %.. _ /-p� D/MENS/ON A Z FT. DESIGN CR/TER/A /vsto D/NA N B�FT NUMOER.OF BE10ROOMS 3 D/MENS/ON C `S',S FJi`2/n/: GAR49AGEO/5P05/IL 4IN17- Now SO/L LOG - TCTAL E3'TI/rWrIED FLOH/'3?cam GAL.1DAY. SOIL. TEST lid! SOIL TEST-*Z 'SOIL TEST (UMBER Q •4CX/bG'pITS 1 f-ECE✓. SZ,O /"ELgY .DATE OF SOIL TEST 7. Ci��3 S/�E LEACH/NG PER PLTSC�. /�T. t i 9oTTOM'LrC�gCN/NG PER P/T 7� O Z Z' RF$uLTS It//TNESSEG BY �E�'4 / SQ. FT o L p �� PER COL AT/ON RATE At/ Lass M/NCI/NGN: TOTAL LEACH/WO AREA 267 SQ, FT. TD P50 iL AExCOLAT/ON RA7"E 2 Tip `�MJN.�INCH RESER1iE LE4C'NING AREA 2�7 SQ. f T. / & - . j✓ F G Ltd T 4`tz�/��i r/G JI�`�. LvE 27 163 RGIBERT ^� y EEC?EDG A RSE ��;1 No.10.951 4 ELOREDO&lemr-IN6ERING CO,lNC. � $'^ r •; P�hFSGisT 7t2. MAIN S:T., HYANN/5, MASS. Li NAL���o�_ ,= � NO GRO�JND YY�4TE/r ENCOUNTERED CL/ENT: IaR—ENdR 7-7— b'3• paGEC D lJNO Yti/<►TER AT EL E�% ./C7B ND. B z 2 0 G saE�- o� r �LG1 C3 33— 7 ` ( rcj l�r.iG o 'IV 37 D U w CF Sib li Q �� pad�E7 iAy --! ti :kA. kOBER7 ', S ` rjHucr /C APE EL7R.EC I r( un Z1 ° y RSE —' v iY� Et i 'No.10951 ��G f .L: o /sl weew ` ONAL�N6 �z SZ,S O LEGEND _. EXISTING SPOT ELEVATION 010 CERTIFIED PLOT PLAN EXISTING CONTOUR ---- 0 --- FINISHED SPOT ELEVATION L�w� FINISHED CONTOUR 0 APPROVED # BOARD. OF HEALTH Q- ��� I N Oh . A241 � DATE , . AGENT SCALE' / _ 'I DATE %d i/R= LDREDGE ENGINEERING CQ /N Ct,l$NT _ - I CERTIFY THAT THE PROPOSED EGISTERE REGISTL�RED JOB MQ. 8 ,� BUILDING SHOWN ON THIS PLAN CIVIL LAND CONFORMS TO THE ZONING LAWS E GIN EER UR DR.BY' Ate,,,,,; OF 9ARNSTA®LE, MAS 712 MAIN S T R E ET. CM. BY.; ...t.... t` HYANNIS, MASS. l� y3f -� � x' SHEET-` Of Z DA E -��:REG. L�� 7-%ND SURVEYOR 20 FT M/N. NO /F E/TNER THE SEPTIC T ,C OR iw LEACHING P/T AA&r ..MORE TNA/V /2"B�tOtN' /O 0w7 M/AOI 6;R.40Ej 1 24'O/AMET.ER C'ONCRsF7 F COYE.Pt- SHALL BF BROUCN7- TO 6RAoE.�AN - --,Ie Y GONCRl7B 4'PC P/PC �EAYY CAST/RON COVER SN,44L OE US,,F�O /N. .o/TCN e:. G'•OYER.S 1 • /F/rV ,DR/VEyVA e 2� MiN. C'ONCRL�TE A :=• — GAVE COVER CLEAN .SAAIAOI •- _ UQu/D LEVEL � - _ 4N C.•1ST ; !..�... 2'LAYER IRON P/PE. f Li b v o o P %4•Pe•R/7. GAL. D/ST. p s o t • • • a . • • • v m4o WASHED S72�NE SEPTIC TA/VK , d „ • . • • • , e. , BaX O B • ►1' � -' • ° e 1 . DEPTH • • I.• • 0 WASHED STONE t / O r _ s �oo� t f • • a • • • ' o p o 6f, ga /,a 79 . n. a 1 • . • • • • • • p ••p PREG45T SEEPAGE INVC L'LE✓AT/DNS r ►• 1 • `• . . • • • a v P17 OR EQU/v.. INVERT AT Ql//LD/NG 3 9 FT. 6 FT D/.4M. /NLET SEPTIC TANK 3 8.8. FT• /O FT OIAM. �� C CS2`E 7>WVLAT/O/V> OfJTLET SEPTIC 7AJV A< FT, /NLET D/STR/AO&WON BOX 3 8 q FT. GROuNo PIA7ER 7A I-r 2-�•Z OtlTLETD/STR/B[!TION /NLET LEACHING PIT . 38,E FT SEWAGE O/S/oASAL SYSTEM. G�r.rw �-s L E.ACH11V49 PIT 7ABIILATIDN DESIGN CR/TER/A DI�L�asfON S�f'T. NIJMQER OF BEDROOMS 3 D/MENS/ON C �8 FT�i'2'�n.�� lf�� TiARQAGEDeSPo•SAL uw/r tior SOIL COG TOTAL ESTI/'%4TEG Fj-4L)*/6 G.4L.14A,Y. SO/L. TEST A/ SOIL 7F57-.02 SWL TEST IVUM8ER OF 4J-4CM/N4 P/T.�i_.� EL�b! Z p E _-7 �/'E-3 f -- DATE OR' S®/L TEST •' S/OE LL�AGH/NG PER P/T SQ Fr. t r 7$�s RESULTS N//TNESSED 'BY-j 140 OTTOM6 G PER P/T S4, .A r- � L O�.,,� �. PERCOLIIT/ON RATE J*/ LESS LECH/ AREA MM/INA.�VIlNNCCHTOTA T V �S )MERCOLATIONRATE/*Z H� � RESFRVELE4CH/N6AREA Z67 SQ. FT � :L 1. 2. J Lam/�---•� \: � „ � ,�a •;,�' f � - Gv T• 4 4- /it's r/G '�/-r' r�,�t.✓E a - - + t m � ✓1 a �InRSE u, � •^ ' EL^u�'.EDG �� ^ �t No. 10951 O DREDGE 4"=Akr NE PIMG CO,I NC. C v 7/2 MAM ST., 14),-A)VN/9, MASS. t 3,• �` ` `�` y$ Cr• y 0 NOG.ITOCINP kV,4TffR EJNCOUIVTE.eEo CL/ENT. •''.'c^"ic4rFa,- - GJ'tO ji V,0 yV11 TER A7^.ELL•'(/. 2G..S / a.r/� �.JOB NO. 8 Z 2 a G SHEET%OF LOCATION_ L6* a VAW NO. Q" o2o2u7 VILLAGE -41 LLB DATE 4� •Z5 83 APPLICANT C� I�LR.QIEI D$ Odv?PM �.IT �C4Q�P FEE ADDRESS GE 1 IL ' TELEPHONE NO. 'I"? ��,(Non refundable ENGINEER ELC awak IN -MiZ,Nis* TELEPHONE NO. "1'iSI ham. DATE SCHEDULED JdlL`( UP ..�_..,._..... Applicant, signature a . • • • • • • • • O • • • • • • • O e • • O • • 0.1.!• • • 0.0 0.0 0 A 0 0,00 4460 • 0 A O O's il 0• 0 0.0 • • 0^0 •.•0.• • •,• 0,0.•.0 •• 0.0 •0 • ; I SOIL LOG SUB-DIVISION NAME QEE t 0STC- ILl "DATE o : 144 S 3 TIME 9. a EXPANSION AREA: YES ✓ NO JoN Lt R. . ELLI S ENGINEER 'N TOWN WATER✓ PRIVATE WELL ,ja4'-w j A C4 Fb 1 BOARD OF HEALTH J 1 AA D,i.t SCq L L. EXCAVATOR SKETCH: (Street .name,etc. ,dimensions of lot, exact location of. test holes and percolation tests, locate wetlands in proximity to test holes NOTES: ON \v LdT ®° o° PERCOLATION RATE: < 2 A TEST HOLE NO: ELEVATIOitTEST HOLE NO: ELEVATION: 1 l I 2 0 2 3 3 4 I i . 4 - 5 2 Z z 5 ® L&ff cd -6 6 J. 3ov- 1 to 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: r NOTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST A ICATION ORIGINAL: COMPLET D IN A RNED O BOARD OF HEALTH COPY! RETAINED BY APPLICANT. i