HomeMy WebLinkAbout0014 COPPER LANE - Health 14 COPPef Lane
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INITIATIVE
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LOCA 1 SEWAGE PERMIT NO.
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I N S LLER'S NAME ADDRESS
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tUILDER OR OW ER
DATE . -PERMIT ISSWE D f ��
DATE COMPLIANCE ISSUED -/G- �4.
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Allpfiration for Disposal Works Tonstrnrtinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair (X an,Individual Sewage Disposal
System at:
...,�. .. . '=--- _ .......................... ......... ....--.........-••--...._---....---- ..---•---•----.-•..._.----....................
�Q ^Loca
n Address i�/
� r�Lt IN o
................ • ...........................................
or Address
. ...............••--••-............................ --
Installer Address
U Type of Building Size Lot...........................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
a Other—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-------------------_ Diameter.................... Depth below inlet........--.......... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by........................................................................... Date........................................
W
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P.' ..............................-............................
O
Description of Soil..................�5&'O --.f...gi'.«.- --------...............
................
.--•.......
.......-------------
..........------
U ---------------•-•----••-•------------......--••--------------•-----•----•-•----------........---•-•----------------------------------•---•....-- .•..._............._..............---•--
W
V Nature of Repairs or Alterations—Answer when applicable.. _: ._'_ L�,d " ..... . . ......
...-----•----------------------------------•------•------•-•-•-•------------•-----------•----•-------.......--------------------------•------------------------------------•-••-••-•---•-•--•-•-•-----••
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iI I'Li 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has tftriissued by the board of health.
Signed.... .. 1 ��` '=''d� ... .(.
�� Date `
ApplicationApproved By..............................................................•----••--..............---.......... ........................................
Date
Application Disapproved for the following reasons:-----•----------------••---••---------------------------------•----------------•---------------------...........
..----•---•--------------•---•-----------...-----------...----•------•--•-•------••---------•---••---•---•----•----- -•--•----..../.......------------------....-------•••--------_..
90 Date
PermitNo......................................................... Issued...................................................
Date
No ..�.'/ F�s..�,, ,
THE COMMONWEALTH OF MASSACHUSETTS
�. BOARD OF HEALTH
ff r
'....�...:...... ...... ............................................................................
Appliratiun for Diupuua1 Workii Tonsirnr#iun Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair (A) an Individual Sewage Disposal
System at:.
r OF Location-Address t/ or,Lot No.
_ / _f/: '
_ Owner Address
Installer Address
UType of Building Size Lot............................Sq. feet
�-, Dwelling—No. of Bedrooms..........................................:..Expansion Attic ( ) Garbage Grinder ( )
`4 Other—Type T e of Building No. of persons............................ Showers —
a YP g ---------------------------• P ( ) 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..................... Diameter...................._Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ), Dosing tank ( )
`-. Percolation Test Results Performed bY........................................................................... Date........................................
� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..................-____.
rT Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-------------------------•.................-•--•-------...--•-----------•--•......•••.•-----.........................................................
0 Description of Soil::`:..... , __
.. . . . . . - -
V ....... ..... .. ......... . •---- --.......--- --------•-----•--...•--•-•-•-•---•--••-•-•••----------._.......-----......._----------•-.
;
W •••••-•-----------------------•••-------•--•-----•-- ...........................................................................................................................................
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 TILT E, 5 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....................•-•----••------------------------.....------•---••------••..-•--
Date
ApplicationApproved BY................................................................................................... ........................................
Date
Application Disapproved for the following re¢sgns:.............................................
.................••••--•-••••----•-••-------------....--•-------•---•-•--••---7--
a.. Date
PermitNo.......................................................... Issued........................................................
Date
♦ „4;'.,fir..
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I M ^C&L
DATA
THE COMMONWEALTH OF MASSACHUSETTS
fiBOARD OF HEALTH
................I ....................OF....rt............... ............... -1 ..................................
°Ifrrtif r'atr of (to lianrr
THIS IS TO CERTIFY, That tkie,dridividual Sewage Disposal System constructed' ( ).or .Repaired ( ,
. ....................... .
by-•-•.................................•...................-----•--•---•-•--- = -
'Installer
/ . i
has been installed in accordance with the"provisions of T t!� ` of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No..-- ...... vy.............. dated.-....7.!!I- '- ......................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.............................................................................._. Inspector................................................:,..................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH,
N�z- L/......... FEE......... ..........
BioposAl Workii (1plonoJtr ion amit—
Permission is hereby granted---_--'-=-, _. ✓ ....?'/ ,...l;...... ....__.•.... _ .. . ..° -
to 'Construct (. ) or Repair (�;:) an Individual Sewage Disposal System
atN ....................
Street
as shown on the application for Disposal Works Construction P r it No. ... ...... Dated.....,/`�'I .. .............
....... ...... -- . . . . ... -- - ----------------------------
..•.•.---....•--...... Board of Health
DATE......�,':A�`- ---------------------
FORM 1255 H0813S & WARREN, INC.. PUBLISHERS