HomeMy WebLinkAbout0075 KATHERINE ROAD - Health 75 KATHERINE ROAD
Centerville
A 228 - 060,
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THE COMMONWEALTH OF MASSACHUSETTS
-BOARD HEALTH
�S
a � Appliration -for Ditipu,itt1 10orko Cnowitrurtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ) an Individual Sewage Disposal
System at: pal
oc iorf-Add o or Lot A. ll C
--- �- ---• L --•---•------••--•--....... — ........................................................
_)j O er �7/r' Address
a // -----"---
Installer Address
Q Type of Building Size Lot----------------------------Sq. feet
V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------_.---_--_- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
P, 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------------------ST ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed bY........................................... .............................. Date--------------------------------------
a Test Pit No. 1----------------minutes per inch Depth of Test Pit.....----.---------- Depth to ground water....------.----------.
�14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water_....-------_---..--..
P4 ----------------------------••--•.•.-------------•------•-•---..•------••-•----•-•---•---•--•-•---"-----------------------..... ----------------------------
0 Description of Soil.........................................................................................................."------------------------------------------.------------------
x
V ...................................... ..................................------••-•-•-------•-----------•••--••--••----••-----------------------------------------------------------------------------.
W -------------------------------------------------- ----------------- - - -----
U Nature f Repairs Alterations Answ r when ap icabl --=f� ' -
O p '
:��. -------- -- - --
Agreement: ,
The undersign: 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 issued by the board of h alth
Signe ---- . --�------ - _ . ....................7
Date
Application Approved BY -•-• -- -----•--•-���' -------/�-f-rz f -
Date
Application Disapproved for the following reasons----------------- -- -• ..--..-•...--.-------------------"----•----•---••--------------------
.......................•-----------•------•-------------------•-"-"-"-•-----------------•-•---•-------------------------•---------------------•--•••-•---•----------------•-•--••----------••-•--•-----
Date
Permit No......................................................... Issued.../� � ....
Date
o
ol
OCQTIOKI 5EWQC;E PERMIT U0.
VILLAGE
IW5TQLLE 5 UL1,NlE DDRESS
BUILDER 5 1.! VA ADDRESS
DQTE PERKA T ISSUED -I,---
DATE CONIPLI &&ACE ISSUED -lp
9 � � ��� �
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6
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No.. ....... Fick 4",...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
oF.........
{'
App irtt#inn -for Ui,spnotti Workii Tono#rnr#inn V rrnii#
Application is hereby made fora Permit to Construct ( ) or Repair l-4) an Individual Sewage Disposal
System at »..-
`� ..... cis. .. .........................................i... '...... �.". { .. i...
Location Addres r or Lot No.
...= :--`- .-fs--------------------•-------
a `-''• f �� Owner ,/� t`"'"'", -------••---------------•-------...._.._Address....-------••----•---...----------------••-
V.
� Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
per, Other—Type of Building ............................ No. of persons..__..--.--__._-__.____.___- Showers ( ) — Cafeteria ( )
a' 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.
3 Seepage Pit No---------------_--- Diameter.................... Depth below inlet.................... Total leaching area---_-------.___..S(l. 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-...___-.-__-._.--.__...
�14 Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water_-._-______--_-..-_----.
a -•-----------'------------------•------•---'••--•-•---••--'•------••----......--•----••-------•-----.........................................................
0 Description of Soil.......................................................................................................................'---.._-_..-------------------------------------
x
V
W ---•--•----------------- ------------------- --------- ------ .........................
`` r
VNatu�rse/of Repairs�o`r,��Arlterationsi—Answer when ap lic�a^bl <�r%- -^ �'� �` ✓ �� ��.... ...... ......
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��i ,.......................................... ........... ............................
�/
Date
Application Approved BY......... � r( ./1 '•l.. v "� ----
Date
Application Disapproved for the following reasons:...........................7............. ...................................................................
------•-----•-----....--•--••---"-•••--'--•-•---'--'•...................••-•'---•------••-..._..•--•-••-----'•••-•-•---•-------......--•-•-------•-----'---..........---'.............................
ate
_ L
Permit No.. Issued.. 1...............................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF -HEALTH
..............OF..............i.l..... `...c''�.... ........................................
(9rr#ifirtt#r Tontpliattrr
THI$'IS'T CERTIFY, That the Individual Sewage, is Sal System constructed ( ) or Repaired ( )
byA `r ..... w max. •-----'---• --------------•-----......--•-••------
! :/ -
at._.e,_.r� _� -;y_.. ,,,.' 'r' > '->t'i,t�'y s'{..•.................. wf..p._.� 1�9..f, -.,a... .,y____ .._.-._............_...........................
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.-? j .......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...................... ..................................................... Inspector.•. ...............................................
THE COMMONWEALTH OF MASSACHUSETTS
.� BOARD O-,F HEALTH /fir
d •+ •I y .....................
.. ........
< �f .. ....... .....O F
No. .. ....... FEE.....,_ ...............
�i��ro�ttl, ork,� ��n�n�#rttr#inat anti#
Permission is hereby granted...... - __._ ?_.:._._ "' __' ._ .................................................
c '�°-.
s .....
to Construct ( ),.or Repair ( an, Individual Sewage Disposal System If,,)
at No._%. !l? ' t _ '?` " ' i >';R,_<_,tt.'t....
't - ^----••-Y•••.....__,. ..- Street
as shown on the application for Disposal Works Construction Permit No.z�............f,.. Dated.....!_._'_ ........................
oard`of Health f• "" ........
...................
DATE...r:...k(....:- ,W (f
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS