130 Septic Application Permit & Perc Test CHECK OR FILL IN WHERE APPLICABLE
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
:Jr? OF tea .14,"tart
Application for Disposal liforko Tough-action
Application is hereby made for a Permit to Construct ('1 or Repair ( ) an Individual Sew ge"HtSpbsal
System at:
Pf> . Lot ,i: 46
Lac t.on
tiro. rid', Sack, r�i.I
ddress
r or Lot No.
b 414 TOT ,i I ti^. 54 5. 0<c?ace R...._....
Owner Address
j'.I d 1. a . 1u. Ii:!. If JCtear
Installer Address ' I i Ac-
Size Lot t
Type of Building
Dwelling—No. of Bedrooms .� Expansion Attic (r ) Garbage Grinder (M)
Other—Type of Building PI'S. No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow 5< gallons per person per day. Total daily flow 331 "lions
Septic TanjePT Liquid capacity I"'� gallons Length 7$E Width 4n Diameter _ Depth
Disposal T-4 a —No. ....._...__..... Width VA. Total Length 34 ' Total leaching area 'VIE sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area. sq. ft.
Other Distribution box ( j) Dosing tank (o')
Percolation Test Results Performed by ri I+ '='%.' . a =- +'^'- '-V°t°q Ae Date 417''1`
Test Pit No. I ' minutes per inch Depth of Test Pit 'eq.: Depth to ground water
Test Pit No. 2 9I. minutes per inch Depth of Test Pit V4. Depth to ground water IV 4
Al 1
Description of Soil fin' +s ' (0-- "5, J.
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 Environmental 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
a.
Application Approved By r�f y,5.j'_
Application Disapproved for the following reasons. / 7
Dan
Permit No. Issued
eve
THE COMMONWEALTH OF MASSACHUSETTS
OF
BOARD OFD-IEAL�
Certificate d Compliance
THIS IS Te CERTIPy Th. he Individual ._ Disposal System constructed O/) or Repaired
by _. _>. r _ _. t , / - \\
at L30 ft' s
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code//aysd/�scribed in
the application for Disposal Works Construction Permit No. 33— L.S dated // F-p-{-y.6.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. ^ ` �%
DATE �/�—LC- Clir S� Inspector if/'/�LCI: C�/� -i
No —
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF (LA.
7
„L
flispdza1 itiorkn Glnuntrurtinn hermit
Permission is hereby granted 44,2r -5-- ..r-. .f-NN A.C.-
to Construct ( or Repair ( ) ali Indiv)lu_a_l Sewage Disposal System
-
at No -ta-7,--_f 76 / Y ll el�it-.2rr'•ti st,
as shown on the application for Disµoka /orks Construction Permit
(J/ q 7/
DATE �ne—?;. ..?2
Form 1255 CH&W j Hoses&WARREN M' Publishers
'/- 5-75
re/
Boa f Healt
i��
' LO ._m &' • re - :-.1nrci7 11
PERCOLATION TEST(S)
Time: I Time:
Observation Hole #1 Observation Hole #2
Depth of Perc S Depth of Perc
Start Pre-soak q /5 Start Pre-soak
End Pre-soak w End Pre-soak
Time at 12" ) . d / Time at 12"
Time at 9° ID ;/ Time at 9"
Time at 6° /, J ? Time at 6"
Time(9"—6°) '?J3 Time(9"—6")
Rate Min/Inch l/ • Rate Min./Inch
'minimum of 1 percolation test must be performed in both the primary area AND reserve area.
Performed by I Performed by
Witnessed by Witnessed by
Comments:
tb1
•
On-Site Review
LocationADate or lot#
Address
dew .
�?O
Date
-
Eng neer or Sanitarian
Weather
-cw
CQ�,y� _
c
Engineering Firm
4ANIMMI
f!
Identity on Site Plan
Land Use
001044
Slope%
Surface Stones
Vegetation
� �rC�I.
JJ -- --�� T f9 F' £.-,,y_—6,-.7-0-0-01-‘
Landform
Position on Landscape
Distances from:
Open Water Body
/1/o
feet
Drinking Water Well
/ 1 zo
//e)
feet
feet
Property Line
Other
3z;
feet
feet
Possible Wet Area
,e.e -
feet
Drainage Way
SS- l
Deep Hole#:
DEEP OBSERVATION HOLE LOG*
MINIMUM OF TWO HOLES REQUIRED AT EVERY PROPOSED
DISPOSAL AREA
Depth from
S ace(inches)
Soil Horizon
Soil Texture
(USDA)
0'7-s
— �
Soil Color Soil Mottling Other
(Munsell) (Structure, Stones, Boulders, Consistency.%Gravel)
o —U
L.)
I I /
i.
nor 54
.—t .�ti.M ,
_
Parent Material(geologic) I
Depth to Bed
7 --•
Depth to groundwater. Standing Water in the Hole
� Weeping from Pd Face
Estimated Seasonal Hgh Ground Water
((je t'
`%)7-
Deep Hole#::-
DEEP OBSERVATION HOLE LOG*
*MINIMUM OF TWO HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA
Dept from
Surface t Inches)
Soil Horizon
Soil Texture
(USDA)
Soil Color
(Munsell)
Soil Mottling Other
Structure.Stones.Boulders.Consistency.%Gravel,
Parent Material(geologic)
Depth to Bedrock
/i ' -- -
Depth to groundwater. Standing Water in the Hole
Weeping from Pit Face
Estimated Seasonal High Ground Water