HomeMy WebLinkAbout0084 DUNASKIN ROAD - Health (3) -<DU41-7 a,4_
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No.2-153LY
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SUSTAINABLE
FORESTRY
INITIATIVE
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No.__/
THE COMMONWEALTH OF MASSACHUSETTS
- _T24 BOARD HEA TH
V _. ............OF........... ............ .... .. ... ....................--.....................
Apphration -for Ditipmat Workii Tonlitrurtion Vrru it
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at
- ----------------• ---------•--------._._..__.._......
Loc io ess ( or Lot W.
b '..• '--
wner Address
W
Installer Address
d Type of Buildi g S.ize_.Lot____________________________Sq. feet
Dwelling— o. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ' )
p, Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures -----------------------------------------------------------_-----------•--------
W Design Flow............................................gallons per person per day. Total daily flow................................!...........gallons.
WSeptic Tank—Liquid capacity---_----___gallons Length-----------_--- Width................ Diameter-----...._.----- Depth................
xDisposal 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_-------._----__-.__..
rzq Test Pit No. 2----------------minutes per inch Depth of Test.Pit-------------------- Depth to ground water.......--______-----_...
P •------------- ------------------•----------------------- ----------------- k------------------------------------------------------
-Description of Soil-------------------- -- - --- -------- •-------------
U -------------------------------------------- ---- ----------------
__-----------------------------------
U Nat e of P.e airs or Altera ions—Answer when applicable. .- ---- ------- ---- --_.-.-. ---.... ____
s - --�:
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 f health.
Signed.- --- ---- ----• --- ------------------------
• � Z� _
Application Approved By----- - �'. . ----:--• � �lL ---14 .. ,..
Application Disapproved for the following reasons:--".fit= ---------------- --------------------- _._-----------___---- ....
P J "" `
�,,.J6 °"��r "y F /4.'. a— C;wa- =
Date
---•----------
PermitNo......................................................... Issued...................... .................................
Date
S
a
Finc
THE COMMONWEALTH OF MASSACHUSETTS
BOARD t-6EA TH
--.:OF..._.. . :. _...... :.-... ........
Appfiratinn -for Bitipoiitti Works Towitrnrtion Pprutit
Application is hereby made for a Permit to Construct ( ) or Repair- ( �an Individual Sewage Disposal
System at:
... ••
. . . ---- -------
to h es or Lot No.
-
• •- --- .... ......................................... -••-•----•---•-------------------------••....---
wne Address
a ........... ----•-• ....................... --•---••-•-
Installer ". Address
d Type of Build g Size Lot____________________________Sq. feet
V Dwelling o. of Bedrooms---------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
pi , Other—Type of Building................................ No. of persons__.______:__________-______ Showers ( ) — Cafeteria (
Other fixtures
)
a w ,
W Design Flow.............................................gallons per person per day. Total daily flow......._--------------------------------....gallons.
1:4 Septic Tcttik—'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 ( )
aPercolation Test Results Performed bY--------- ---------- -------------=--------------------------------------- Date-------------------------------------...
Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water---______-____-__-_--._-
t14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water............__.-____--_-
P4 .......... •------ --------------------•-•--••--••-----•--•---------- ------------------•-- ----*-------------•---•------•---•--•---------------------
O Description of Soil__ ________________ ___.____ .__.___
t� --------------------------------- -- ------ ------ ------
411
W ------------ - ------ --- --- ------ ------------------------------
VNat re of Repairs or Alter ions—Answer when applicable ""'_ t _ .-____ _-_::. -. -_- __;
f s
------ . .-_ _.� , -- �, - w.;-- ----------------
Agreement:
r
The undersigned agrees to install the aforedescribed Individual Sewage Disposal 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 bee issued by the board f health.
t Signed- --- -----
............. �P---- Date
Application Approved BY-.- �/ ' --- -= " /
v - > at1
Application-Disapproved four the following reasons:--------------------------------------r__ ____________________-..__.._._.._______:______-__-__.__.__-__.__---__
--•••••••--------------•--------•---•- -------------------------•-•----------------------------------•----------_---------•----•----------------------------------•----•-•--••--------------------•----
Date
PermitNo.•_-...................................................... Issued'-----------------------, •-----...................
. ' Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
:.. ............OF.... '. .............. . ..
uprrtifiratr of Coriipt14turr
T IS O C R" , „what-th Ind vidual Sewage Disposal System constructed ( ) or Re ( .
by - ---•• - ` ---•- ------ ---•••--
In t",ller
� r
has been installed in accordance with the provisions of Arti6lc.,Xl of The State Sanitary Code as esct abed n the
application for.Disposal Works Construction Permit No-- dated__.-_. ..
THE ISSUANCE OF THIS CERTIFICATE .SHALL NOT.•.BE CONSTRUED AS A GUA ANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
C`a a.'.1-1 'rye•} '.. 4 r s�' - �*"'T
- - 1..
`�.�, 'Inspector /yi��.►�r!"",
t�' t„S.L4'Yfra �W tr„r ,. ., a .`?t .+a.•ro+:nr'`ir'.!:'�- -M... _ .. - �
9� THE COMMONWEALTH OF MASSACHUSETTS
Aft 1y,.4
JJ- BOARD OF `LTH
Y
OF.............
.. ..-.. ,.
FEE....�":•.....
�ih�po k5 C txnrtion Vrrm t�,.
Permission is hereby grante _____ _-____ _ _ -------
to Cons't�( air ( a ndivi wag Disposal em
at No. -- liRry j' ;, ---- .....................`
----
.k .`treet
as shown on the application for Disposal Works Construction Pe o--------- __ _ �.
•f ___ ____• --------- - •�___ - __
Board of Health r�
DATE-------------------------------------------------- -==-'--------------------•---
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
- 1 .
41,