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HomeMy WebLinkAbout2615 MAIN ST./RTE 6A(BARN.) - Health 2615 MAIN ST., RT.6A,BARNSTABLE - A=258-047.001 _ .r a ,y v ' a r p . C t u • • 4 4 i IY y r. '.,.n• ..� :_,__Y- yr ...=-e.�„ �;.:—x - ii-Y- t..L :��,.=w;Y=w ei�tw._z c-it�•f'• —�:��}sw'�r. •`y._ � _"_ .- .. -. —. vW .. •• -. �:- ..__:."� Y+'v,-1r .. —_ _. _"� .._ +'�- w� r—x _ u a Yl Town of Barnstable P# 2 Department of Regulatory Services : .eRrrereStE Public Health Division Date 7ZSj seJ 9. �s$ 200 Main Street,Hyannis MA 02601 + rEO MA't� Date Scheduled Time -L Fee Pd. Soil Suitability Assessment for Sewage ViSP7t Performed By: / K`�I Witnessed By: LOCATION:& GENERAL INFORMATION Location Address 6 �S /, Owner's Name LI A Address garns-�� 2. Assessor's Map/Parcel: s8_d 7 0 0( Engineers Name NEW CONSTRUCTION REPAIR Telephone# Land Use Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) t a Parent material(geologic) Depth to Bedrock 2 t Depth to Groundwater: Standing Water in Hole: �.� J Weeping from Pit PAee...... Estimated Seasonal High Groundwater - DETERM r1ATION FOR SEASONAL IYGI3 WA -TAEL Method Used: Depth Observed standing in obs.hole: in. Depth to sail mottles: Depth to weeping from side of obs,hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor _.. Adj,Groundwater level PEROOLATIOr1 TEST Ta.p Observation Hole# Time at 9" — Depth of Perc Time at 6" Start Pre-soak Time @ Time(9"-6") End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) y E w C P*4ty f Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1) week prior to beginning. Q:\SEPTIC\PERCFORM.DOC DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel t� 2 a I- Fy 1 ` 2 5 2, DUP OBSERVATION HOLE.LOG Hole# 3 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel ja DEEP OBSERVATION HOLE LOG Hole# '- Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.' Consistency,%Gravel et 2 1 l 2 DEWOBSERVATION HOLE LOG Tole#^ , Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,To Gravel) L L t z1 2 ^ Flood Insurance Rate May: 1 q, Above 500 year flood boundary No_ Yes 4— Within 500 year boundary No�u Yes Within 100 year flood boundary No— Yes J— Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? _,�__YU5 If not,what is the depth of naturally occurring pervious material? Certification I certify that on t (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed'by me consistent with the required training,expertise and ex erience described in 310 CMR 15.017. Signature / Date Q:\SEPTIC\PERCFORM.DOC TOWN OF BARNSTABLE _ 4p . LOCATION � �3 Ca SEWAGE# Z �' VILLAGE --?A RAC P tit ze ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. FJ c.sl,o Sc e. C. 2 7 SEPTIC TANK CAPACITY (J-00 -7-AV/r , LEACHING FACILrrY: (type) (size) NO.OF BEDROOMS BER OR OWNER jy�; v PERMTTDATE: Y�? -COMPLIANCE-DATE: 4`f`--2 Separation Distance Between the: Z' Maximum Adjusted Groundwater-Table to the 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 eachingfacili }, 's Feet I Furnished by ��2✓ is �.. - � .. � � y �• �` �' i � � Y ��� Y ",. �� .. ,,, v , � r �� :y i - "::F. ....._ a ,� .r .� M N � � �`I MI` i � � No. r ri ! Fee vU THE COMMONWEALTH OF MASSAZHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for Digpoar *potem Construction Permit Application for a Permit to Construct( )Repair Upgrade( )Abandon( ) O Complete System individual Components Location Address or Lot No. Own^er�'s Name,Address and Tel.No. Assessor's Map/ParcelJ 9� L ��kj Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. • M I!J-c 07-ell—Se^ 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 / SDO C>1 aType of S.A.S. Description of Soil f�! c.tn�— Nature of Repairs or Alterations(Answer when applicable) STAA c-v OD `(dC_ V o' : S`t L G?cw fti S c --3:7, S FAA 0- g►�►-nc 4P 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 lace the system in operation until a Certifi- cate of Compliance has b . 41 Signed Date Application Approved Date Application Disapproved for the following reasons Permit No. Date Issued s— Fee THE COMMONWEALTH OF MASS HUSETTS Entered in-computer: Yes PUBLIC HEALTH DIVISION>r;TOWN OF BARNSTABLE, MASSACHUSETTS T 01ppi ation for M.504-4*potent Conotruction Permit r�y Application for a Permit to Construct( )Repair )Upgrade( ;s)Abandon( ) El Complete System ,individual Components Location Address or Lot No.a6l�_R�r6/4- t-&557r(b�f OOW. er's Name,Address and Tel.No. Assessor's Map/Parcel _0,D Q ` t A. Installer's Name,Address,and Tel.No. Designers 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 00 G1 A-` V_-j Type of S.A.S. S1 .,,___,,,,"__ Desgription of Soil Nature of Repairs or Alterations(Answer when applicable) _—r7,,t--ST a k —'t`ap—f? f' � U In o' ei�r `I �k LC o C (iA't�l= S� {A (\ e p S Date last inspected: j 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 b=�-bq-this-B a — Signed Date Application Approved Date Applc;a'tion Disapproved for the following reasons Permit No. Date Issued —————————————— ——————————————_———————— THE COMMONWEALTH OF MASSACHUSETTS s.. BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the Ott site Sewage Disposal System Constructed( )Repaired ( )Upgraded Abandoned( )by —�' -- at :D. 14, T tv"t Vt S l STc-%o has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. v.G GPI d t d"F'�t�— ZZ— FP Installer Designer The issuance of this permit shall not be construed as a guarantee that the s�s will function d�s�gn Date �� �'' .Wf No. f � ------------------.--------Al FeeX/C3'Cs� THE COMMONWEALTH OF MASSACHUSETTS t PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Qi5pogat *pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair( )Upgrade(l�Abandon( ) System located at n 11 `��g A(L(h.S 1(-, s 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 completed within three years of the date of this t. %✓G Date: �'' � Approved b _ �.rP . t , 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FORA DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANSI hereby certify that the application for di sposal works construction permit signed by me dated --C concerning the property located at �;L(a t meets all of the following criteria: v The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system (I�There are no private wells within 150 feet of the proposed septic system v• There is no increase in flow and/or change in use proposed There are no variances requested or needed. The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] 6-Iff the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) 3 S 0 B) G.W.Elevation /di 0 +the MAX.High G.W. Adjustment. , DIFFERENCE BETWEEN A and B © SIGNED : DATE: [Sketch proposed plan of system on back]. q:health folder.cert d a S 'r a i f TOWN OF BARNSTABLE LOCATION SEWAGE # ?�— VILLAGE_ R.��rt' �� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. .s, E� .� S ,n .� c L' 7790 Z3 SEPTIC TANK CAPACITY E moo VA- LEACHING FACILITY: (type) (size) j NO.OF BEDROOMS_ X/ — BLIbBBR OR OWNER k wy Z/All j PERMTTDATE: 4!��—� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 eaching facility) Feet Furnished by v 1 f ��� No..l..�...-_. �L Fim �E HE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH / —SOWN OF BARNSTABLE Appliratioit for Uiopoml World, Tomitiortion Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( j an Individual Sewage Disposal System at: .4Ae4 2.r jp/q r•ss or Lot No. ............ ......-•......1. ......................... •-•-•------•------.....••-•-•-•-••••••••--------•............••--................................. Installer Address Type of Building Size Lot............................Sq. feet .., Dwelling— No. of Bedrooms--------- ___------------------------....Expansion Attic ( Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) PL4 Other fixtures ---------------------------------- W Design Flow........................ _________gallons per person per day. Total daily flow........ ...................... WSeptic Tank—Liquid capacity., gallons Length----- _.__:_ Width...9---------- 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........................................ �-1 ,4 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ z Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......................... a ........................................................ •-•••••••• .......................................................•..... •..-........ -......... ••- 0 Description of Soil........................................................................................................................................................................ V -------------- •.................... --- -------- --------------------------------------•-•-----•------------•----------.._..-------.._.........-----------••--•.------- W ••••••-•-•-•----------------••-•••-••---•-------......--------.._...._........ --------••••............. 0 Nature of Repairs or A terations—Answer when a plicable._�®..... XOS Lj/?C/.. .._ ._.._.. �°xL► G .. .._l(..��/DUS.f'�.f��..�`54-t- d'�s �_ ------------------•-------•-•---•--..---.--•--••---- Agreement: The undersigned agrees io install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complia d b the bo ea Signed ..... ....... . . a'�3 ApplicationApproved By .......... +J' t1..... t ................................................................. ......�: '_.�. . Application Disapproved for the following reasons: ..... ......... . .............................................................................--....................... ... ...... :................................................................. ... ............................................................ .-............ .. .... .................... `/ �. Permit No. ........��� .. .-� Issued ........./ G ... .e.... ��e...... .'—'"�'—'_`-'..4.41--1'�,};,,y::r, w� � �� r, r•, '� �sl�cr,bi�,Yi.�+'4••w,�y+*.—"'�4ritv;'hrS+*We���•-�J�",-,,;;�'s'r`6'"5i L/.lL.2-...� .. Fi$.... Via....-.. . THE COMMONWEALTH OF MASSACHUSETTS T�} s BOARD OF HEALTH 5 TOWN OF BARNSTABLE Apphratioaa for Diripwi al M rk,6 Tomitrurtinrt rnmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: � � 65,9 ............................................. ------------------------------------------...--------.........._...-------•-•••--••--....--•------ Locations-Address or Lot*No. JU ( /-----.....r---------------------------•--,--....._....--••----/.._ W � q_Al�t /�..•[_. �Ve(!/-� of y dress E ` �/ �G�IC:.._ _�.!. -! __H- {41 A 0 � _ /� f!� / / 0�r q r Installer Address UType of Building Size Lot............................Sq. feet .� Dwelling—No. of Bedrooms---------a.................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons............................ Showers\,( ) — Cafeteria ( ) Otherfixtures ------------`•y ----------------------------------- ------------------------------•----•-••------....._..-•__---- W Design Flow..........................................g Ilons per person per day. Total daily flow...... .......................gallons. WSeptic Tank—Liquid capacity-AND�.gal'Lons Length---.U-_.__.. Width---Y---------- Diameter._............. Depth................ x Disposal Trench— No- -------------------- Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No------------_------- Diameter..... .......... Depth below inlet____________________ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed b7..-`----------------•-----•••------••-------••--------•--••---..._---_._ Date........................................ Test Pit No. I................minutes per in Depth of Test Pit.................... Depth to ground water........................ fT Test Pit No. 2................minutes per inch Depth of Test Pit.................... De-)th to ground water........................ D Description of Soil.............................................. --� _ ----------------- =.................................................2........ 4 .."' S 4. •r-- -.; a x ...........................................•----...-----------.....-•-•-----•--------•.....------------•----•'----------•`-------....--•---••---•--••----•------..._.. U Nature of Repairs or Alterations—Answer when applicable.A.P/iI6. ._ x�5 1�_��/____.... . ____... ........ .._xrt� �tfrj ... C�____�n� _ioUS_ t\-ytf ----- -------- -------- ----------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has-been-iss ed by the board of ?ealth!j Signed �e ...........� '............................ v ----.......... -.......----..-. Dace Application Approved B :....................... 1..�...-..� � 3 PP PP Y u � =-� Dare Application Disapproved for the ollowin rearonr: ......- :.............................................. ------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------- --------------- ................................. n Date Permit No. ........ --- ---- ------------------- Issued --------- ...-`7./........� .................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C�extifi ate of C11ompliance THIS IS TO-CE.RTIFY�, That the Individual Sewage Disposal System constructed ( ) or Repaired ( - by ..... 1 :. J (_. �`d---- .CICS 43-----60 ... ... ._..... .. .............................. . dler at . ............ G l.�i. ; �/�J/:).. .7i. - ! 1`/ ..tl� .............. �T`7 �5./_�C :./ '................. .... has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ................�j..-. ...... dated .....................................___---- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE ........ �..._.. .......r`- ------------------------ _...._._.._..... Inspector ... �-------------- _......_...--- --...- ......----....... -------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � '� TOWN OF BARNSTABLE 'Dispnsl ork� Tu�aar)��trurtilan�-rrrutit ,�(11 Permission is hereby granted.............�(J 'ro, __-(IlY•la� 7 f/,-/.-. � 1 �Fl, O i - • ---•----------•-�_•••----••-•-•--•--•............. to Construct ( ) or Repair (--'�'an Individual Sewage Disposal System at No.................. :_C /`'�`_-...n) fl 1111.-- ---- -f! 6.---- ppp�e'�j. 5�`t street 1//_n as shown on the application for Disposal Works Construct "P' rmit No... _.�"/_]._._1ls�j_I-_ ated...............�1.L....._.._....__._.._. - � ;1 r71 v V Board of Health DATE.......... ......... ----•------------------------------------------- FORM 365081HOBBS Q WARREN.INC..PUBLISHERS FEs......20 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ApplirFation for Disposal Works Tnnitrnrtinn Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( L4-an Individual Sewage Disposal System at: ........�(�..1. .................................................................... ......... i�(�b�a..... .------...---------•............------. .Location-Address or Lot•No.• ."_...... �' l�f 1.Q.!�1---•-•............................... ............... y�-Q............................................................... Own Address a .........C.....f.ao ..Jak_o......S'P. S.(................... ................... �.aM. ....................................................... Installer Address Type of Building Size Lot.................... Sq. feet Dwelling No. of Bedrooms...a g 3...................................Expansion Attic ( ) Garbage Grinder ( ) p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ...................................................... W Design Flow....... ._5.-......................gallons per person per day. Total daily flow...... :C_......... ............gallons. W Septic Tank—Liquid'capacity....__......gallons Length................ Width-____..._____--. Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No.....L........... Diameter..., ...... Depth below inlet....,(-.�.....•. Total leaching area.._...............sq. ft. Z Other Distribution box ( ) Dosing tank ( ) F-I Percolation Test Results Performed by....................................................................-..... Date........................................ a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water..................... ..- fs. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ t4 -------------------------------------- -------- -----------•----.... 0 Description of Soil........................................................................................................................................................................ x U w x .........................................................-.............................................................. U Nature,of Repairs or Alterations—Answer when applicable_..-�l�-.SZ A4t........i...U-z�......(O.1��_--IPXT.......... rib..... S' ` '� 1 CTLD-•5 .1--o Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI:%, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Complian een issued board o health. �, G Signed-- ..................... ------------------- 5.-,f. _-t------ Application Approved B Dace Date Application Disapproved for the following reasons:....-•,----•--------------------------------------------------------------------------------------------•---•- ----•--•.....•-•--•----•-----•-•--•----•...•-••••---•-•-•------•-••••••-•.....•-•.............•••----•------•-•-•••--•-••-•--•-•••-------•--•--•••-•-------••------------•----•-•------•------••--•.... cc Date PermitNo........0. ......................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH —�`owrti o A -s?.1�: . Trrtifiratr of ToutpliFanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by------------------_--- .Y�Yf ...L_.u� -'" S t.(.................................................................................................... `�II�nstaller at ......... T .. ._!9 ..._.....V.i�c _ 5 '......... has been installed in accordance with the provisions of 'T"7% 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 CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................ ..................-------•--.. Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............0F..�� ..w..ski.fib. ........................... FEE. Disposal Works Tonotrnrt on rrntit Permission is hereby granted.. C✓�- t"✓} Spe71Z..----••-----••--------•-------•--•----•----••.......................... to Construct ( ) or Repair (�n Individual Sewage Disposal System at No. ............ .. S.r: :�....------ . 12. Street f as shown on the application for Disposal Works Construction Permit No. _. /\/l.�^��\'.. Dated.......................................... ..• ................................. •A.S..�/_...................................................... DATE.. Board of Health cy -1._.g---••--•--- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ............. FEig THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH UL -aV........O F App iration for Disposal Works Tonstrnrtion Famit Application is hereby made for a Permit to Construct ( ) or Repair ( clan Individual Sewage Disposal System at: ........ �a s....... ..lam. .. �!.. .... ............. � _......, ........................................... Location-Address or Lot No. ......... !..I CULA /--------•-----------•------•----•----- ............... 'V![ `.... - - -...-- Owne Address W --•--..._��V.l�.l..44,. 1- .... �. 4.��.. .............. ................... ------------------------------------------------------ Installer ° .----------------------------------------------------Installer Address U Type of Building Size Lot..................... ....... feet Dwelling No. of Bedrooms-__�-----------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ........................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures - .._.. W 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.--.-J....---: Diameter----/.,='>...... Depth below inlet....&.1....... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation 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........................ ------------ •...... • ..._.... O Description of Soil............................................................................ U -----•••-•--------------------••---•••---..........---•.....-------•------•-------••..----------••. .................................................. W x / U Nature of Repairs or Alterations—Answer when applicable.--. ks. 'IAA�I.-..-�.070.7b... (D• •-- - -....... ------------------•... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iI'=�, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Complian �been e bo�oealth,Sig ---- --•-----•----•-•----••- Date Application Approved By.............. � Date Application Disapproved for the following reasons:.......................................................... f ..................... ..............------------------------------•------------------........................................................................................................................................... � Date Permit No.........0:1:a.f.s-•-------•---------•----• Issued--------------------------------- E ...................... Date