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Home My WebLink About1471 IYANNOUGH ROAD - Health (2) �4'11 �{0.nnov6 h� _(mod �a�7�.� - �5s-Ol'�-x01 APPLICATION FOR• PERCOLATION TEST AND OBSERVATION PITS � - vt- LOCATION �� ` DATE VILLAGE 4 APPLICANT C- �� FEE � TELEPHONE NO. (Non-refundable ADDRESS —' ENGINEER TELEPHONE NO.,-7rz �_ DATE SCHEDULEDdV " (Applicant' s signature ASSESSOR'S biAP LOT NO: SOIL LOG SUB-DIVISION NAME DATE ,� -'s�� „, �� TIME/1411.f EXPANSION AREA: YES NO �'/1/ ENGINEER ?' TOWN WATER_ILPRIVATE WELL BOARD OF HEALTH EXCAVATOR SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and percolation tests, locate wetlands in proximity to test holes) NOTES: is9 o . o N i T_�11 J B` c j 7 PERCOLATION RATE:TEST HOLE NO: -- ELEVATION: TEST HOLE NO: ELEVATION: 1 1 2 2 3 3 4 .4 - 5 5 6 6 7 8 g �� . 10 OJAL 11 rvtEo ��Z N� G�• 11 � ivi 12 GOS la 's 12 A�� ST k 13 ` 13 S IONAt 14 J 14 Yd- �3 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. Eo AND RETURNED TO BOARD OF HEALTH COPY: RETAINED BY APPLICANT t No.... � 9�°_.... � `�'� 1�/ Fz�s....Id..��... l THE COMM WEALTH OF MASSACHUSETTS BOARD OF HEALTH AV-ptiration -for Mapmaal Warks Tiatudrurtion Prrmit Application is hereby'made for a Permit to Construct (V111"or Repair ( ) an Individual Sewage Disposal System at � ------------------------------------- ------------------------------------------------............................ Location-Addressor RA.✓/c, A� ...9...�'! !`< .2� N ` ._ e.eror If :i ...13 y rro / .✓�r!s. . � O� ,�1AA Ogner �/ -7 Address ,L, W C 1�7a ` /q4 �fia (r ��^04 �T a+ r `-`iD t',i, S a 1 w 1� ......... ...... .. ----....---------------------------------------------- -----•--•--- � ;�. ----------------------may ......'b Z s s Installer Address s d Type of Building/ Size Lot..�x4.__'-� �f'�fq. feet U Dwelling K No. of Bedrooms............................. .............Expansion Attic ( ) Garbage Grinder ( ) 114 Other—Type of Building _ ` a.r No of persons..,/W---�E% S Showers ( ) — Cafeteria ( ) W Dther fixtures ...4---*� r��r�s...� �s----.... d /o® ------------ •�'z�l/n i�'' fie, ate,��-. f�t'"�`'r�''SU �® W De ign -Flow---------------------------------��.-_..gallonls per person per day. Total daily ...................._.__.....gallons. WSeptic Tank—Li capacityA-5.�®_gallons Length f..l .._._ Width- -_V.._.. Diameter---------------- Depth.-6`r_'*... x Disposal TrenchR_.-W- -- . Width---- - Total Length------------------_ Total leaching area.._-----.•-------.--s ft. Seepage Pit No.- �..._._._.. Diameter ®. Depth below inlet__--`_------_-- Total leaching are. -3 :._ ----sq. ft. z Other Distribution box (j ) Dosing to ) Percolation Test Results Performed byW__.A2---ip_`� _ 5� � °��Date..../3.��'� �` � b Test Pit No. 1.....2 minutes per inch Depth of Test Pit.._--- '._--_0 Depth to ground water�.�. f� Test Pit No. 2__-_..- ____minutes per inch Depth of Test PiY o. .�'t°Depth to ground watef..V.1_®_`-,_-_-. W ------- 0 Description of Soil------�_<;!n•--- � °'^ ,v �'` '�"'' - - 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 Article XI 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. d .. --------... ........ . . ...•G------------- •-----•- ate/�A lication A roved B !ig -- -•-----------------------------•--- •----•--•------------.....--------------- PP PP Y---------�-�-- -- Application Disapproved for the following reasons____________________________________________________________________ ------•••••----•-•-----..Date-------------- ------------------------------------------------ .....................................- Date Permit No. Issued. --G`3/.. 7�-------------------•--- Date THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH / c� (•... +I.........._....0F....�..................... / Appliratiutt -for Ilia oria1 Works Tons- trurtion rrmit Application is hereby'made for a Permit to Construct (V'<or Repair ( } an Individual Sewage Disposal System atlrl' f ,, ---------------------------------------•------••-------------••-•-•-------------•---•-......--- Location-Address ` p ��,.,G — t urie`✓r/! ''t / jor , t No. eD2K C)� ................................................../ C .rr Owner. Address ...................—- --- --•-------•-------•----•--•------••-........................••... �•—'J7 . ;.. Installer Address Q Type of Building Size Lot. -'rC.I'`.Sq. feet U Dwelling—No. of Bedrooms----------------------------------.--._..-.Expansion Attic ( ) Garbage Grinder ( ) ;L4 Other-Type of Building �- :.%_ -.--- NTo. of persons.; <a v"CC%.,�. Showers ( ) — Cafeteria ( ) P+ i Other.fixtures ff l`ec� a.�w» C r J E h , !w_.�s d /O. CG6. ---- W Destgn Ilow..................._._...__ --_-- glllons per person per day. Total daily flow--/_-`t`.` ..............--_-._.........gallons. �- --- Diameter------_-_---- Depth-_6 - W Septic Tank—Li t capacityL>a°.gtillons Length(l._l ...... Width. '`�` x Disposal Trench o. ..: '._--___.--. Width-_-_._-,-.-----_-_-- Total Length.................... Total leaching area------.------- -----sq. ft. Seepage Pit No.._.�'-----..---- Diameter_--_.---.'-.Q.. Depth below inlet-�- '__:--._.._ Total leaching area?.3P_,_/.....sq. ft. Z Other Distribution box (/ ) Dosing to 0 Percolation Test Results Performed byN+<�-':_. .� .f .- ---v Ss ' A .............. D ate... -_ '� ! --- --� ,-----. Test Pit No. 1--_--2, --_..minutes per inch Depth of Test 'it1. ` ,_::'-'.. Depth to ground water':' .. ........... f=+ Test Pit No. 2------•Zc...minutes per inch Depth of Test Pi;Y..?._.'._... Depth to ground wate'r-D. ..?_:..--...... --------------------------------------------- D Description of Soil...... ...... •-•x " .. -- ° ----------"-•---------------------------------••-------- V --------------------------------------------------------••-----------------•------------------------------•---•--...------------------------•-------------------.....----------------•------------------ W 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 Article XI 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. Signed..- Application .. ------ •---- ,e L ��Clt �_ ?� Datd'� � A roved B /7 PP y--------------------- ------------- ------------------�'-------------- ------------------------- Date Application Disapproved for the following reasons--------------------------•----------------------------------------==° -•-------------------•...........----....----•--------------•----------......----------•--------•----.... _ Date Permit No......................................................... ._ Issued.--,_. � /. 7Z---------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........:.................................OF.... +-_�, S..t� / ................................. �rrtifiratr of 0.11mpiiaurr T IS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (L' S or Repaired ( ) by...... .- "' ----- ....... Installer '= has been installed in accordance with the provisions of :�ft}�le XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No----- .----y_%:.................. dated..'/ ------ ................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE----- - �._ ? s r 3 7 , --•-•--•------------------------------••• Inspector-•--•------------•--------------••---•----......--------------•------•••---•-----•- THE COMMONWEALTH OF MASSACHUSETTSU76 41 J BOARD OF HEALTHOF V-0 � �_ �- No............... 1--•• FEE-1 Di-spoplal ork-s �onfitrurtion V rrntit Perrruct_(i.r�or L#diviclual Se hereby Repair (ed)an • �age Disposal System l-� � ' . � �• to Con t at No....... -"L'-• �"_ / if-'o�,t E L- ""73,-__1 s 3 . ..�w strelit - r ,.. as shown on the application for Disposal Works Construction tit No. ....--,-.--. Dated.._.�---------------------------------------- DATE t J - --7--•---•----------------•---------------------- FORM � oar of Health --�-------------------- - 1255 HOBBS & WARREN, INC.. PUBLISHERS