HomeMy WebLinkAbout0309 BUCKSKIN PATH - Health (2) 309 G3�c�s��
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M E A D
KEEPING YOU ORGANIZED
No. 10334
2-153L
MADE IN USA
GU ORGANUD AT SMS,A COM
6
0.---1 f-. . ( �V FEs.... .
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® F HE L
......------OF...... . ... .... . ...... ........... ...........
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
syst t
- ----------------- --- ................ --•-- ...•-_..
c ton-Address o Lot No.
..yl.._.. -'.... ............................. ..................................................................................................
wner .........................•--••..............Address
.._..
------------------------------------------
Installer Address
Q Type of Buildin� Size Lot__--------------------------Sq. feet
U Dwelling—No. of Bedrooms------------ -------------------------Expansion Attic ( ) Garbage Grinder ( )
PL4 Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
0.' Other- fixtures __________________________
---------------------
W Design Flow.. ........`___ _____________•_-•--_.gal ons per person per day. Total daily flow__._......J---____-.._______-_________gallons.
WSeptic Tank Liquid capacity`.______ ons Length--------------_ Width---------------- Diameter-----.---------- Depth____.______..._.
x Disposal Trench— o..................... Wi h ..___._...... Len Total leaching area....................sq. ft.
Seepage Pit No.__�__-___..._. Diameter.(. �e^�� i4� `.. . Total leaching area e74� ft.
P g c� q
Z Other Distribution box ( ) Dosin tank ( )
01 Percolation Test Results Performed by.........................................................-•••-••-•••••--• Date----------------------------------------
1.4
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..__--_-_-.._--.__-__-_.
fX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................. epth to ground water._______________-_---._.
a - ----- ---------- ------- -------- ,�,�J•••--- -----••---•-•---• ..........••••--•••-••-------•--------•-••-------•---•--•-•-------
ODescription of Soil----------------------- "i" - — ------- - ------------------------------------------------------------------
x
W
x .......---------------------------=----------------------------------------------------•----------------------------------------------------------------------------------------------------------------
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 YI of the State Sanitary Code—The undersigneXfur ler agrees not to place the system in
operation until a Certificate of Compliance has been issued by the bo Ed.of .
Si/gne ---a� . ..... . ..I................
Date
Application Approved BY —_-------_--- ... — ..3'
D e
Application Disapproved for the following reasons: - ------------------------------------------------------------------------•---•-
---------------------------------•--•--------------------------------•----------------•---------------------------------•------------...--•-------------------------------------------------------•••---
Date
PermitNo........................................................ Issued........................................................
Date
Application Disapproved for the following reasons:..............................!�...............................................................
....................................... .................................................................................................................... ..........................................
11 - _/�/7 Date
PermitNo......................................................... Issued-.---- ... ......... ------_--_----
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. ............OF... . .............................
AT
%fr.rtifiratr of Tomptiaurr
T T is �'CER�T Y,That the Individual Sewage Disposal System constructed (iw�or Repaired
by ...... .... ........................................................
Install
........ __ I ��........:............................
at...... --------
has been installed in accordance with the provisions of Article ate Sanitary.0 d descri ed in the
application for Disposal Works Construction Permit No__.... ....../.z*. ...... dated .. .....7 J......
THE ISSUANCE OF THIS CERTIFICATE SHALL BE TRUED AS A GU ANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. � . I . "-k 'n
DATE.................6 .—-7_3......................... Inspector--va-
... ......... ---c-----------�_ --------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTI*
.�al�1
Code
_11- — ,cr i_TJ
... ...OF .................
No.. 4.17�4 FEE.'a
Permission is, ereby granted. . . ......... ------ -------------------------..................................
to ConstrtjctW Repair an Indiv ff ual Sag6 Dis�pp S t
Z . . . ............................................
at -----------1-_f;k...... e c,e. AW-L,4f-v o el-pk��...... ---- -
04� z . Street
as shown on the application for Disposal Works Construction Permit .... ed---- .......
... .. ...... ...
Board of th
. .... .......I.......................................................
Rea
DATE..........
FORM 1255 Ho BS & WARREN. INC., PUBLISHERS