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HomeMy WebLinkAbout0014 BRIARCLIFF LANE - Health (2) 9`f mar Cb* � ao��,os I G 7No ,?1' ..« THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH O �D'5- /! ld ...oF... . 'J?�� �.��, '................................. Appliration for Dig niai Works Tomitrn.rtinn Prrmit . Application is hereby made for a Permit ttoo,CCoonstruct ( ) or Repair (,X) an Individual Sewage Disposal System at: jy ......... -- --•--------------•----••- ......................................... .. Location-Addres or --••No. - ..... � a . ----------------------------------- ......... .Y��.� .......................................... �" .e v�i s------------- - ..--•---------....................--------- Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No, of persons............................ Showers a YP g ---------------•----------•• P ( )--- Cafeteria ( ) dOther 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..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 0-4 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 Test Pit.................... Depth to ground water........................ O Description of Soil................•S.CC__.�.91. Ld / - .......__.......- - ._....:....__. x UW ••••-•-•--•-----------------•••••-•.-------•--••--------------•---....--•---•---••••-•-•-•••.....••---•-•-••-•---- ........ Nature of Repairs or Alterations—Answer when applicable TA n ; ..................... ...---••---••-••-•••-•-••--•-••-•--••----••-••--•--•------•-•-•....••••••--•-----•-.....------•----•-•------•---••-•----•--•••-••••-••-•••••-•-•••••-••-••--•-._.....••---•-•-•.............•-•--•----• . Agreement: - The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State SaAbee e— The undersigned further agrees not to place the system in operation until a Certificate of Compliance sued y th�oa�g9f healthSig Date Application Approved By----- •-• lf ......................... ......./Z7 1.-- � Date Application Disapproved for the following reasons:................................. ...........-• .............. .........-•-•----------------•--------•---•--•---------------...-•--------------.......-•--•------........-----•--.........------------------------------------------------------------------•-••----•-•- Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Tntif irtttr d fanmPlianrr THIS Tg�,�TIFY, That e Individual ewa e D osal System constructed ( ) or Repairedby ./ �i��. ' .. - ' ' - C,?/ .-C----------------------------------------------------------------------------- r�----�iro.� .2Z _------------_------•••-•---------•-•-----------•------•�,��'����� has been installed in accordance with fhe provisions of T _n��S 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..•10V.._7.s .__.__-'... dated_._..1 -._.S'-- THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.........................•--..................--•---•--••--------•-•---•--.•.... Inspector.................................................................................... Fps.. :..«:.. ......... .... THE COMMONWEALTH OF MASSACHUSETTS BOARD .OF HEALTH. f... l...OF. Appliration for Disposal Works Tontrnrtion Vamit Application is hereby made for a Permit to Construct ( ) or Repair (;.:_,) an Individual Sewage Disposal System at: C..«.. r .....:.....:.....:..«.:..----------------:.-----------:--_ .................................... ..........__........__._.................._... .......................................... Location-Address or Lot No. ............Owner-----___._•--•--........ - — ...................Address........................................... f ! p� Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Pk Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ..---•-------------------------•-----------...----•---••-•••--••-•••-••--••••••••••••••-•--••------•............ W Design Flow............................................gallons per person per day. Total daily flow.......................-....................gallons. WSeptic 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 ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water........................ G�. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a .•••--•-•-••••••••••••••-••••••••••••••••••••••••••••--•--•-••••••--•-•-••.................••-••••••........................................................O Description of Soil____________________________ __..............___________ ....................................................... --------------------------- W U .________________________________________________________________________________________________________________________________________________________________________________________________________ W U Nature of Repairs or Alterations—Answer when applicable........... "__ .................... ••-•---• .................... ---------------- ------....-•-------------------------------•-----------------------------------••-----.............-----•-----•--------------------...•.•------•------11'-`-----------------•--••-•-•__--------••-•••----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T ITUE, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has issued y the—board, f health. Sigd .. .. ......•• •-•--•-- '•='• ` ••'•• -•-- ��q �rl Date Application Approved BY - -- ........-----•--.......... -- �l` "' '� Date Application Disapproved for the following reasons:.............................................................................................._................ Date PermitNo........................................................... Issued.--.................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 4l OF......y .5?i'1 t�'F .. ?. .` rf r Tntifiratr of Tomplianrr THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ;(l;Y�)�©r rRepaired (� b .... = t J_ ,_ f/!/( , � '� ` r .'.= ......__••--• --••-_... _.__.._. r, Installer /r r has been installed in accordance with the provisions of T _L 1 5 of The State Sanitary Code as described in the +•r'"" '—..,,.application for Disposal Works Construction Permit No... __._7,�'4e_........... dated___.-,/r/ _1":"`77.............. 1 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector............................................... .:. THE COMMONWEALTH OF MASSACHUSETTS e BOARD OF HEALTH g ........._.j . r No......... _._ Disposal Vorhg Tonstruction Vrrufit Permission is hereby granted....-,... =-=-------1_ t* f_ :� r= `. _----{---.......:......._•...'__.........................................' to Construct' ( ;) or Repair O an,Individual Sewage Disposal System � f y - ( } ;. Street g as shown on the application for Disposal Works Construction PeprffiV No . _____ Dated_____1 "= ` ' 7/ Board of Health DATE..... -- --••-- --•-----_!.'------------------------•-•-••-••••-•-•......• VVV FORM 1255 HOBBS & WARREN, INC., PUBLISHERS