HomeMy WebLinkAbout0061 POWERS DRIVE - Health -o k eys b r t,6-e-
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I
No.... Fmc..... ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF EALTH
...............
_�7t:55:rlw",-------- OF............. .e&�.
Appliration -for Bwpoiial Works Tow5trurtion Prrutit
Application is eby made for a Pe_7rmi,...LConstruct 1( ) or Repair an Individual Sewage Disposal
System at:
....... . .... .......... ...... ....................... .......
..............................................
-
--------- --------------------
------------0 at' _... 'Z_r,ess Lot NQ,
...... . ........ . ..................... .... ...... ......... . ..... . .... . .................. ......
0 r Address
j........ ..... ........... ... .... ................ ........ ....... _0 ..................
Installer AL
e of Buildi Size Lot............................S ect
Dwelling No. of Bedrooms----------------------_-------------------Expansion Attic Garbage Grinder
Other—Type of Building ---------------------------- No. of persons........ -------------------- Showers Cafeteria
04 Other fixtures ----------------------------------------------------------------------------------------------------------------------------------------------------
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
IY4 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. 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------------------------
Test Pit No. 2................minutes per inch Depth of -Pest Pit----/................ Depth to ground water........................
----------------------------!-----------------------/--------------------------------------------------------------------------------------------------------
0 Description of Soil--------------------------------------d................................ ------------------------------------------------------------------------------------------
x
U ..................... -------------------------------------------------------------------------------------------------------------------------------------------------------- ..... . .
------------------------------------ .................... -----------------------------------------------------------I-- ----
------------2t-------------- ---
hen applicable - --------- ---------
Nature of Repairs or Iterations Answer ------------- .... es
-------- ----
.............................. ------- --------- .... ----
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 b1n issued,bj the. bo7d oWfhn alth.
-----igne ... . ... - -- -- ---------- -- ........... ..............
Date
Application Approved By------- -- --- ....... ...
te
Application Disapproved for the following reasons:-------------------------------------------- ------------------------------------------......................
................................................................................................................................................... .......,-----------*4 ...21
-------------------
----/Da/te P , i;a`;
PermitNo......................................................... Issued----.... .. .... .............
-----------------------------------------------------------------
No.... � -- Fins..... ......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF EALTH
y- .........OF............. .. .
�
Apphration -for Dhipoiitt1 Workii Towitrnrtion Vrrniit
Application is hereby made for a Permi , Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: ;
Y
--------------------
l;af.•-Ad ress --•---o--Lot Nq. .
-----==� - ---- -----"�": ..............•-••• --- = -----
/�j,�J O r Address
Wj` �t ��-.•-•----- "�" r ----------
� � Installer � •� �•�d�rts_s �j+�/'`
d e of Building j Size Lot____________________________S eet
U Dwelling No. of Bedrooms________________________________ .Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures _______________________________ _ _
W Design Flow....................................._......gallons per person per day. Total daily flow_____________________.__________-_-.-._ -_-gallons.
P4 Septic Tank—Liquid.capacity------------gallons Length................ Width------._....... Diameter--------------- Depth.---------------
W Disposal Trench—No_ ____________________ Width--------------------- Total Length-------------------- Total leaching area-._.-__-..-_._.-----sq. ft.
x
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 "Pest Pit-------------------- Depth to ground water..-:-----_--.___--.-..-.
f� Test Pit No. 2-----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
ODescription of Soil------------------------------------------------•-----------------------------------------------------------------------------------------------------------------------
U
U Nature of Repairs or ]terations—Answer w en applicab ...____...._ _._._. ._.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
j 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 b n issued b the box}d of alth.
igne �!� ..........
/ Date
Application Approved B . G. y _
ate
Application Disapproved for the following reasons____________________________ ____________ _________................................................_........
-----•-----•-----------•-------------•••-----•--••-•••----•-----------•------------------------•----•---••--------------------------•--••------•---.-----•••-•-•--•---------••------------------------•-
Date
Permit.No......................................................... Issued......................................----------•--:
Date'
THE COMMONWEALTH OF MASSACHUSETTS
BOARD Of HEALTH
............I .t ! .................O F......... , ✓i�.- . . v. ....................:.......
Af4;' , Trxttftrtttr of f�untrltttatrr
THIS IS TO,C_ER'TsIFY-,,,.T at the Individual Sewage Disposal System constructed ( ) or Repaired ( )
�.. .rah �.s., ....�.....'------
bY•---•-•-•- F -----------------------•-------•----------•----._...-.------------------------------••-
< s' tnst111er
has been installed in accordance-with the provisions of Article f The State Sanitary Code as described in the
application for Disposal Works Construction Permit No--------
,
t
" ate
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 OF HEALTH r
f .
4 }NO.__ � ._ FEE_...`......
_.
Pemission is hereby grante -- -- -----
toF
Construct�'( or Rep r ( an Individ,al Sewage Disposal Sys em
---
at No. (1�/ ,�f = . ----- �' -------- 1 .-
eet �
as;shown on the application for Disposal.Works Construction r it No. tted __________________________
4441<
. _____ ________ _____ _ __ --_ __--.--_ .. ...-__. __..__. ____...________----.-
i Board of Health
DATE........ ...............................
FORM 1255 OBBS & WARREN. INC.. PUBLISHERS