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Home My WebLink About0021 KNOTTY PINE LANE - Healthvz_ k ' tTtY Prof LN iT II I'I No.7.F THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..,OWA_V............OF......1. ..44,MY44-11-1............................. Appliration for Mipviial Works Tomitrurtion ramit Application is hereby made for a Permit to Construct or Repair ( Io<an Individual Sewage Disposal System at: /Y* V t.4mde...............�Imp ............................................................................. Location or Lot No. O ............................... W-1 ......................... Address .................................................................................................. Installer Address Type of Building Size Lot............................Sq. feet U Dwelling-joil<o. of Bedrooms--------------------------------------------Expansion Attic Garbage Grinder ( Other—Type of Building ............................ No. of persons---------------------------- Showers Cafeteria ( Otherfixtures ...................................................................................................................................................... Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacity............gallons Length................ Width___............. Diameter..._.._..._..... Depth..............._ W x Disposal Trench—No----------_-------- Width..............._.... Total Length..............__.... Total leaching area....................sq. f t. Seepage Pit No..................... Diameter.............._..... Depth below inlet.................... Total leaching area..................sq. f t. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.__.__._............ Depth to ground water_____________-_____.,__. 0-4 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................._. Depth to ground water._..................._.. P4V--------------- --------104-------------- *........**-------*----------------*----- 0 Description of Soil........a4r*�. .................(5,444. 1... . ............................................................................................... ---------------------------**,-*----------*----------------------------------------*..........-------------------------------------------------------------------------*.......*------ �V I ................................................................................................................. ..........4------------ ----- --& U Nature of Repairs or Alterations—Answer when applicable_....-.___:'' ------- ...... ..tk.1 ..... ....................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TL 1'L!L- 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 thn boar of health —0-4 Signed... ..�e ... . . .. ... ..... Application Approved Cl— I - Date ...........................................................0....4....1n.:r:...................... --------------- ...... Date Application Disapproved for the following reasons:................................................................................................................ ........................................................................................................................................................................................................ Dat PermitNo....... ......................................... IssuedL....................................................... Date LOCATION SEWAGE PERMIT NO. ' Ill CE ` INSTALLER'S NAME i A,DDRESS J � (� liyl� o � h �2 s Sam B U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED l/J/� t,j 'e I x �Tp 3 S 1 . ` A . 3i LOCATION SEWAGE PERMIT NO• TILLAGE 4fZ- I' U Z 4 F1 1��5, ::g I.NSTA LLER'S NAME i. ADDRESS 8UILDER OR OWNER 6614 arc N,r k,05. DATE PERMIT ISSUED Z271- DATE COMPLIANCE ISSUED i c? No- Fnx THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ _41V.............OF..... ............................... Appliratiou for Disposal Works Tonstrurtion Prrmit Application is hereby made for a Permit to Construct or Repair (ioij"an Individual Sewage Disposal System at:. .............................................................................. Location-Address or Lot No. ........................... ................................................................. ............... ........................................................ �41 Owner Address -A ....... , ............................... .................................................................................................. Installer Address Type of Building Size Lot............................Sq. feet U Dwelling ;1L. of Bedrooms...........................................Expansion Attic Garbage Grinder A P4 Other—Type of Building ............................ No. of persons____________________,_______ Showers Cafeteria Otherfixtures ..................................................................................................................................................... Design Flow............................................gallons per person per day. Total daily flow...........................................gallons. 1:4 Septic Tank—Liquid capacity............gallons Length________________ Width................ Diameter__-_____,_______ Depth_______.___._... 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. I................minutesperinch Depth of Test Pit_.._._..__.__.______ Depth to ground water_._._._.____________.._.. 44 Test Pit No. 2................minutes per inch Depth of Test Pit._.__._____________. Depth to ground water________________________ /................4..... ...... --------------�4...... 0 Description of Soil .. .. "---------"""--------------*---------------*------------------ 7-------------- .......�Ze' ..... ......... .... ........................................................................................... U ........................................................................................................................................................................................................ ................................................................................................................. ...........I.............. ........... . ---- U Nature of Repairs or Alterations—Answer when applicable--------- .............................. F~ ...... ............................�V.......................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beery issued by the board of hey lthSigned . .........;;;;:.......................................— .....7-1 ------------ Date -2 ly�/� Application Approved By..................................._.:........................ .............................. ............... I Date Application Disapproved for the following reasons:................................................................................................................ ........................................................................................................................................................................................................ Date PermitNo------- ------------------- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 0 F................................. ..................................... fit TZUS 4 TQ,,JERTIFY, That the IndividuaLSe-A,age Disposal System constructed or Repaired ......................r,..A................................................................ z;............................................................................ Installer ............ . ...............................................at..... ...... ------11Z -------- Kee --- ............................... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No_________________________________________ dated-------------------------- ..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM.WILL FUNCTION SATISFACTORY., ci— DATE........................................................ --- Inspector--------._....._-------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH J/ / ............ OF......... ................ No. .............. Dioposal 10orhs, Tonqreurtian Vqmit Permission is hereby granted--- ................... ....... .................................................. to Construct,,(. ) pj-R jeT an"Individual Sewage Disposal 5ystem atNo...-- oxe it:................... ..................................... ......................................fll:k..................................... Street � l_9_Z3 as shown on the application for Disposal Works Construction Permit No..--af!................ Dated.P'?/__? 'e................... ......................................................................................................... Board of Health DATE................................................................................. FORM 1255 A. M. SULKIN, INC_ BOSTON