HomeMy WebLinkAboutApplication - 130 MARIAN DRIVE 4/27/2012 TOM/N OFINMR111 ANIHM/FM
Office of C()Mkll�NITY I)EN ELO 111M FNT AIN WS'I",IZV ICES
HEALTH DFIA"AR"I'M EN T
1600 0,SGOOD S] 111,Af:T; BUILDINC211; SIATI,2-36
NIOWI I N ANDOW"R, NIN��','SMA M d,, E]TS M 845 cm
IYM6W(540 Phoy�e
Susan Y. Savvyvr, R[AIS/Its 979,688.8476 FM(
Public 11ca111h Director 1:,-M AIL:
SEPTIC PLAN SUBMITTAL FORM -""RECEIVED-
e.-.f - �1�
Date of Submission: ,,
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I'Ovw,,,t a s NOM,14,1 ANt11(11VKR
HtIALI$I MORI�M�1M,,2N`r
Site Location: 62' k1A 641 Ml V Cl�
Engineer:
New Plans? Yes V�i'225/P�in Check 10 (includes Is'submission and one re-
review only)
Revised Plans?Yes $75/Plan Check
Site Evaluation Forms Included? Yes No
Local Upgrade Form Included?111 Yes No
Telephone#: h Fax
\,- f
E-mail: t Q, t) L-1 e,,,), 0 p, C 0, 1 6AX
Homeowner
Name: IJ['I�_
OFFICE USE ONLY
When the submission is complete (including check):
Date stamp plans and letter
Complete and attach Receipt
Copy File; Forward to Consultant
Enter on Log Sheet and Database
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Commonwealth Of Massachusetts
..5 r
' City/Town Of "
Percolation
N N
Percolation test results must be submitted with the Soil Suitability Assessment for On-site Sewage
Disposal. DEP has provided this form for use by local Boards of Health. Other forms may be used, but
the information must be substantially the same as that provided here. Before using this form, check with
the local Board of Health to determine the form they use.
Important: It Information
When filling out ,
forms on the
computer, use --------
only the tab key Owner Name
to move your 1970 �
cursor-do not Street Address or Lot#
use the return
key. -
Citylrown State may. Zip�Code
rab a / 204 y
Contact Person(if different from Owner) T iep' ne Number
. Pest Results
9 al'Z�
Date Time Date Time
Observation Hole# p
Depth of Pere
Start Pre-Soak ° l
End Pre-Soak
Time at 12" I �'
Time at 9" I
Time at 6"
Time(9"-6") I
Rate(Min./Inch) —
Test Passed: [ Test Passed: ❑
Test Failed: ❑ Test Failed: ❑
Test Performed By:
— -------------- —
Witnessed By:
Comments:
t5fomn12.doc•06/03 Perc Test°Page 1 of 1