320 Title 5 Perc Test, Applications/Permits 1975, 1976, 1996 FORM'2-PERCOLATION
Location Address or Lot rvo. ��
COMMONWEALTH OF MASSACHUSETTS
.Massachuserts
Iligammems
•Minimum of 1 percolation teit must be Pertained in both the
reserve area.
primary area AND
Site Passed ❑ Sita Failed ❑ -
Performed By-
Witnessed By
Comments;
•
ev.nmnmmw.ianm
t`
t. y 1
sin .., .._ ..
1. u. i
n„ddrese or Lot# � .
Lora'
Hcis Number
Date
-1 3 h Time ?;� , Weather
cJ
p
Location(identify on site plan)
Sol
bottling
j Land Use
i,,,,,r— I Slope(%) I I Surface Stones I
Vegetation
,L
r
Landform
,.. ..
Position on Landscape(sketch on the back)
Distances from:
I
Open Water Body
- feet
Drinkinq Water Well
feet
Properly Line
feet
Possible Wet kea
feet
Drainage Way
feet
Other
feet
DEEP OBSERVAT ON HOLE LOG*
Deep Hole fit 'MINIMUM OF TWO HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA
Depth from
Surface
Sad Horizon
Sod Texture
(USDA)
Soi Cola
(MUnsea)
Sol
bottling
Other
(Structure.Stones.Barters.Consistency.%Gravel)
(Inches)
, 'r.
-1 //-
Other
(Structure,Stones,Boulders.Consistency.%Gravel)
Surface(Inches)
i
_II_
I
I I Depth to Bedrock 1
Parent Mahal(geobbc)
Standing Water n tie Hole
Depth to
_ --7 )
_- I Weeping from Pit Face
gwdaater
Estimated
Seasonal Hgh Ground Water
,
Weeping from Pit Face
Depth b grouMwater Standing Water
Estimated Seasonal High Ground Water
DEEP OBSERVATION HOLE LOG*
Deep Hole If: 'MINIMUM OF TWO HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA
from
Sod Horizon
Sea Texture
(USDA)
Sol Cab
(Mum")
Soh
boding
Other
(Structure,Stones,Boulders.Consistency.%Gravel)
Surface(Inches)
I
( Depth to&
— Parent Mahal(geobgh)
m the Hole
Weeping from Pit Face
Depth b grouMwater Standing Water
Estimated Seasonal High Ground Water
FEE
THE COMMONWEALTH OF MASSACHUSETTS
MASSACHUSETTS
lion for Pismo( gstent Construction Permit
S On-site Sewage Disposal System at:
App
made for Permit to Consnuct( ) o ( an
Location Address or Lot No. Owner+Name.Address and Tel.No.
3aa Nom F RD, ON) C sxo,
3N) N, RAT S
ler s Name.Address,and Tel No
ti
fJ
Designer',Name,Address and A- ift lis O5�
.•a
Type of Building: JJ/ ,�yag�pp}(
Dwelling No. of Bedrooms No. per Persons
Other Type of Building �'t1
Other Fixtures
Design Flow
Plan Date
Title
De
Son of S
Ot
gallons per day. Calculated daily flow
Number of ,eels Revision Date ''T�
0
3 Z
Showers( ) Cafeteria( ) , _},
5�, 7,rY�°qqAr�� �
gallon /
/ 0
N
Nature of Repairs or Alterations(Answer when apphcab
rm.A
Date last inspected:
The undersigned agrees to ensure the construction and maintenance of the aforedescribed 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
Certificate of Compliance ,-en issued by tars Board of Health.
Signed ...." fir
Date / 2 v `
Date
•1 /O ,.
Application Approved by
Application Disapproved for the following reasons
Permit No.
Date Issued
'V s
/6
Fri
THE COMMONWEALTH OF MASSACHUSETTS
.MASSACHUSETTS
tton for ! p°SnI `�gstem Construction Permit
made for a Permit to Construct( )o ( an On-site Sewage Disposal System at:
Location •f -ss or Lot No.
3a6 Aio2'p-h Ptglm5 RD ,
eisNa °-
Install
me,Address,and Tel N
Type of Building:
Dwelling
Other
Design Flow
Plan Date
Title
Des
Ou ner's Name.Address and Tel No.
ON IC. IAG RA, S
396 AL frrems RD, Alm inp,,)
Designer's Name,Addres and Tel. No
, N u l S ps
)%IET -hyI7t � r
5-2'7-gal/
Calculated daily flow --
Other Fixtures
c No.of Bedrooms l
Type e o f Building No. per Persons Showers( ) Cafeteria a G
444
6
ion of S
gallons per day.
Number ofs•eets / I
win
7rvi l:L' lid s/�ilA1• /°Siren
Revision Date
u AI JI'lr'•
gallons:
1 VJ
'�la I`-.
- fICIWhsr3e!
Nature of Repairs or Alterations(Answer when app licable
6r D/se sM Sy$
REncsu r s'8
7AA-DA20 a' 1b C
Date last inspected
Agreement:
The undersigned agrees to ensure the construction and maintenance of the aforedescribed 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
Certificate of Compliance -been issued by this Board of Health.
•
Signed
ApplicatiotlAPProved by
Application Disapproved for the following reasons
Date Issued
Permit No.
Date
Date
M/6
T Fr COMMGNWEALT OF MASSACHUSETTS
,MASSACHUSETTS
zi
Certificate of Compliance
Q CERT/ y tbpf the •e I`(osal System installed
by
a'
(bccorda e
for
)or repaytedl replaced (4n
/
'J(
'has pfensopstructed in
9 ' /Y ,/ - dated
provisions of Title 5 and the for em is col System Construction ompli c Permit No.
Use of this system is conditioned on compliance with the provisions set forth below:
hall potche construed as a guarantee that the system will function as designed. This
}
The issuance of this certificate
Certificate expires op
DATE
No. _�
Inspector
THE COM�MP NWEALT OF MASSACHUSETTS
Oj L- MASSACHUSETTS
Pisposat ' em Construction Permit
Permission is hereby granted to
to construct( ) or repair(y/)an On-site Sewage System loca
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.
All constructiorpmust be completed withinthree years of the date below.
( , ' Cie Approved by
i
t ere
FEE
DATE
FORM 1255 Ref 3.95 Pal-ILK!
CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
FEE,5.I&..d I
Appliratinn fur' linpimat 3flurkn`�unntrurtinu 1)erntit
Application is hereby made for a Permit to Construct ( ) or Repair Klan Individual Sewage Disposal
System at:
cr-
3.01 ra
e.:91aLild.eatio lddress
efrn Owner
Address
ID s l]er Address Sq. feet
Type of Building Size Lot q
Ex ansion Attic ( ) Garbage Grinder ( )
Otheri—Type of uildinoms -_.--- - Expansion
of Building -- No of persws Showers ( ) — Cafeteria ( )
Other fixtures g`ellon..
Design Flow gallons per person per day. Total daily flow
Septic lank— Liquid capacity gallons Length Width Diameter_ Depth
Disposal Trench—No. Width __Total Length _Total leaching area _ sq. ft.
Seepage art It
Other Distribution box ( ) Dosing tank ( )
Date
Percolation Test Results Performed by Depth to ground wate-
Test Pit No. 2 per Pit No. I minutes per inch Depth of Pest Pit I
minutes per inch Depth of Test Pit Depth to ground water_
Description of Soil
Nature of Repairs or Alterations—Answer when applicable
a cA e..d, ... wee
The undersigned agrees to install the aforedescrihed Individual Sewage Disposal System in accordance with
Agreement:
the provisions of Article NI of the State Sanitary Code—The uudersigne further agrees not to place the system in
operation until a Certificate of Compliance has bee issued by the board heal[ -
Application Approved By
Signer
4,70.
.- •_
Application Disapproved for the following reasons'
I ppips=
/- Issued 1_{-7»
Permit No_.6 1.f% Uri=
CHECK OR FILL IN WHERE APPLICABLE
No
THE COMMONWEALTH OF MASSACHUSETTS
FEE
BOARD OF HEALTH
OF
Application for +Tioponal ifiorko (tonotrurtion Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair (b) an ludisidual Sewage Disposal
System at:
Locanon.Address
or Lot No.
Address
Owner
Address
t^'('�" Size Lot Sq. feet
Type of Building Garbage Grinder ( )
Dwelling Type of Bedrooms Expansion Attic ( ) )
Other—Type of Building
No. of person- Showers ( ) -- Cafeteria
Other fixtures g:dlon>-
Design Flow gallons per person per day. Total daily flow It lle d
Septic "Fmk—Liquid capacity gallons Length Width _- Diameter sq. ft.
Width Total Length Total leaching area
Disposal Pit No Depth below inlet Total leaching area I. ft.
Seepage Pit Nn Diameter P
Other Distribution box ( ) Dosing tank ( )
Date
Percolation Test Results Performed by Depth to ground wate-
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 ! g
Description of Soil
Nature of Repairs or Nterat ions—Answer when applicable
0
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
Agreement:
the provisions of Article XI of the State Sanitary Code—The undersigne further agrees not to place the system in
operation until a Certificate of Compliance has been/issued by the board health! I•
Signed' J - /
Application Approved By
Application Disapproved for the following reasons
G Date
Date
Permit No
Issued
Date
by
at
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Trrtifittttr of anmplittntt
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
(
maalier
DAT
Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_(.' _OF J, _. FEE_.
No Y 11
Pinpnsttl ilhprktt onstrurtinn hrmit
Permission is hereby granted_
l
to Construct ( )
or Re air ✓} an Individuals Sewage Disposal System
j
at No :ewe
as shown on the application for Disposal Works Construction Permit No_a
Dated
Bp,rd of Health
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
CHECK OR FILL IN WHERE APPLICABLE
No...R../-,b Fux.% ' 6 0
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF
(HEALTH
Applirtttiun -fur +J3iRpuuttl 3turkz (uuiiruriiun llrrutii
Application is hereby made for a Permit to Construct ( ) or Repair (1.') an lndiridual Sewage Disposal
System at: G-
3a b _ r
or Lot No.
a[cration 1 dress
7 n nq,nc 4 / Address
I"•i��nY'VY / p
Installer
Type of Building
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Budding No. of prrsons Showers ( ) — Cafeteria ( )
Other hstures
Design Flow gallons per person per day. Total daily flow gallons.
Septic Truk—Liquid capacity g:dlons Length Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Dosing tank ( )
Performed by Date
minutes per inch Depth of Test Pit Depth to ground wate-
minutes per inch Depth of Test Pit Depth to ground water
Address
Size Lot Sq. feet
Other Distribution box (
Percolation Test Results
Test Pit No. I
Test Pit No. 2
Description of Soil
E-
Nature of Repairs or Nteruions—Answer when applicable ---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Di posal System in accordance with
the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issue. by the board of health.
Si
Application Approved By
•n a
40 0
Application Disapproved for the folio
y reasons'
cfefrtilm
Permit No 6 7 4
Issued
V
/q75-Late
Z.5'
oet�
CHECK OR FILL IN WHERE APPLICABLE
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
FEE
1 pplirutiun for Disposul Works (nonstrurtiuu Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an ludiuidual Sewage Disposal
System at:
-Location-Address
Owner
Installer
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow gallons
Septic T:nk—Liquid capacity gallons
Disposal Trench—No. Width
Seepage Pit No Diameter
or Lot No.
Address
A rid rear
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
No of person= Showers ( ) — Cafeteria ( )
Other Distribution box (
Percolation Test Results
Test Pit No. I
Test Pit No. 2
Description of Soil
per person per day. Total daily flow gallon..
Length Width Diameter Depth_
Total Length Total leaching area sq. ft.
Depth below inlet Total leaching area sq. ft-
Dosing tank ( )
Performed by Date
minutes per inch Depth of Test Pit Depth to ground water
minutes per inch Depth of Test Pit Depth to ground water
Nature of Repairs or Alterations—Answer when applicable
N, r g
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
Ext.:`..CGI
Application Approved By
Application Disapproved for the following reasons
Date
Date
Date
Permit No Issued
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
airrtifirate of tdumpliaure
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
Ins m lle.
at
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No dated
THE ISSUANCE OF THIS CERTIF'CATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
l OF
Dispaial-iBturks (gnnstrurtiun '1rrmit
FEE
Permission is hereby granted
to Construct ( ) or Repair ( ) an Individual S7age Disposal System
at No
as shown on the application for Disposal Works Construction Permit No Dated
Hoard of Health
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS