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Home My WebLink About0079 AUTUMN DRIVE - Health (2) �� Aut+wm n p ri vt. No.... Fsim.12,.................. THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEA TH dc_r �a..........O F......... ... Appliration for Disposal Works C onstrurtion Prriait y Application is hereby de for a Permit to Cgp§truct ( ) or Repair ( ) an Individual Sewage Disposal S stem 1, (,,.1 _ _ - -------- .................................•---•---•-- ---- •----------•--•• -•---•----- ocati�. ress vor Lot No. ....-----•-----. r3....... �L............ . .. -•••-----•--------------------..............-••----••---•-•-•------------- ----••- � , Ow'er _ �<�—�{�`�:Z'b� dress - ••--•-••---- l........ -•---.......•....... -- w--•--------•......... ................. .... ................................................. Ins al r Address Q Type of Building ,(L�E� Size Lo/era 62...........Sq. feet m�I -Dwelling°�No. o Bedroo ...............eo. .....Expansio ( ) Garbage Grinder ( ) PA Other—Type of Building �.. persons. Showers (� ) — Cafeteria ( ) d Other fixtures.�. W Design Flow....................... ._.__gallons per person per day. Total daily flow_---__--�--- --"---------gallons. WSeptic Tank—Liquid capacity/lS66--gallons Length................ Width---------------- Diameter____-_______-- Depth---.__..__...__. x Disposal Trench—No_____________________ Width---------_--------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..........'--------- Diameter.................... Depth below inlet.......i............ Total 1�' ching area_-______--_._...__sq. ft. Z Other Distribution box ( ) � Dosing tank ( ) Co��. - -0 ,4/ aPercolation Test Results Performed by........................................................................... Date---------------------------------------- Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_____________________._. (Xq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Soil----- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- W UNature of Repairs or Alterations—Answer when applicable------------------------------------------------------_--------------------------------------_ . =•-------------------•-•---...---•------•-------------------....-•--•--•-•--•------------------------•-•----•-----••----•--•-----------------------•------•------------------------------------ Agreement: The undersigned agrees to install the afored ed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanita . Cod —The undersi ed further agrees not to place the system in." , operation until a Certificate of Compliance ha b e ssued by o f health. Signe .. -•---- --•----•-••• ............ -•----------------•--------- Application Approved BY f - ------- --- ---- ----- - -- -- 'L r' /gate �� e Application Disapproved for the following reasons:.........----------•---•---•-•--•--•--------------•-•-••-------•---•-•-• •-------------------------------------- ......•••-•---••••-----••-•-•-...--••-....•••--•--•--------••-••-•-----••-••------••......•••-•..........................................------•--•-- PermitNo......................................................... Issued Date Date Nod-1 `•---------` FICA.............................. THE COMMONWEALTH OF MASSACHUSETTS � B®A R F�HELT l ----..._..OF..: . .:....:.: ...... _::... - Appliration for Ehap anal Words Cnomitrurtion rrmit Application is hereby a for a Permit„ nstr tc (� or Repair ( ) an Individual Sewage Di 1 system �:_� -..._ --------------- ..................... --- - - - - ----.---- - ---- cati ddre@s t or Lot No ............................ �� Cam ................ W Owner Address --_..... ------ .. � Install r r '`-- U Type of Building Address YP g l_ Size Lot..�JrJ__�. .--___Sq. feet Dwelling—No. of Bedro __ :................................Exp ttic ( ) Garbage Grinder ( ) aOther—Type of Building ... No. of person :... ..................... Show rs ( ) Cafeteria ) Otherfixtur . •---•--•-•-----------------------------------------------•------------------------ fk --- -- Design, Flow..................... ..................gallons per person per day. Total daily flow.___. _ ---------gallons. Q,'. �', Septic,Tank—Liquid capacity -___--gallons Length................ Width-.--.._.. .:_ Diameter_._._.......... Depth............. .- W x Disposal Trench—No..................... Width.................... Total Length -__ -_--. Total 1 aching area.....................sq. ft. Seepage Pit No..................... Diameter.................... Depth be w i et ____ hiag d e -------------sq. ft. Z Other Distribution box ( ) Dosmg,tank ( ) a Percolation Test Results Performed bY-------------------------------........................................... Date........................................ Test Pit No. 1...............`minutes per inch Depth of Test Pit.................... Depth to ground water----__----__-_---..-___. (� Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water_-__:-___----_-__•____- P4 -•----- •••••. ,., Description of•-Soil.............................. ---------------------------•--....---------------------------...---------------------------------------------------- W;t s- F., -- ------------•--------------------------- U Nature of Repairs or Alterations—Answer when applicable_ ____________________________________________________________________ _ .-------------------------=----------------------------------------------=-------------•-------------------------------------------------------------------------------------------------------------- Agreement The undersigned agrees td 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 a Certificate of Compliance 'operation until has been issued by the board of health. ti Sign ------•••• jl Application A- roved B ,a,. Date Application Disapproved f or the f oltowing reasons__________________ --------------------------------------------------------- Date Permit No..........................-............................. : Issued. -= +... 4 �. ,.Date,.. THE COMMONWEALTH OF MASSACHUSETTS. ' BOARD ; F HEALTH ' x rt rrtif irtttr of Qlampli�lna t ''' T TO CE_I�fII "' �a h I ' �3ewage Disposal System constructed ( ) or Repaired ( ) bywtt �i -- ------------ ---- ------------------------ In at ------ - - T,;has been installed in accordance with the provisions of Article X_0* State Sanitary a�*, s t�a the application for Disposal Works Construction Permit No----------------------------------------- dated...................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE.CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL)FUNCTION'SATISFACTORY. ` t r� DATE........... •.. . 6 ......... , Inspector r� .ri ;j 2, t ---------- -- THE COMMONWEALTH OF MASSACHUSETTS B0A'7DAF HEALT .............:............................OF................................................... ..... No..........=--------•••-• FEE---------------•----•-- Perm 'on s .ereby gran d---- -•--- ---- + to Cons ) a&4air al ew al at No. ----•-• t et as shown on the application for Disposal Works Construction t o. _ ____._._ ........... --•-----•---•-------•-------------.............•---- DATE. ................. Board of Health FORM 1255 HOBBS & WARREN; INC., PUBLISHERS