HomeMy WebLinkAbout0046 BUCKSKIN PATH - Health (3) LAO 6c4CK51�r
V,
#
d
y
fi
i
d
No..s 7/v---...... Fps 4......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
G 4f�-
Appliration for 43itipwi t Murky Tomitrurtion Pauli
�( Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
.^' Sys r r
V.....- -- ---• ... --------- ---•••.... -- -- ` •----•---------------•------•-•••....•--L�D ..
�olat Address or t No.
� u
..__.. .. - - _. ..... ._. .. .. .................... ........... - _ ..--..---...--..................--........._.._...._._._.._......__....
r Address
nsta ler Address
U Type of Buildi � _ Size Lot__l. ____ .___. q. feet
�-, Dwelling-1ZNo. of Bedrooms........... -----------------Expansion Attic ( ) GaZige Grinder ( )
PL4Other—T e of Building ....... No. of persons............................ Showers — Cafeteria
p' Other fixtures.......................................................
W Design Flow........................... --- ------Er Ions per person per day. Total daily flow------ --------------gallons.
WSeptic Tank/-Liquid capacity _ __ ___ llons Length................ Width_-------------- Diameter.•..--_______-- Depth__________._._
x .Disposal Trench—No-______________•_--_. Wid h-__••___-_ �_Q__ Total Length..___________.___._ Total leaching area_____.__-__-_.____--sq. ft.
Seepage Pit No.;::................ Diameter / Depth below inlet._............ Total leaching area"___?. ft.
z Other Distribution�ox ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date.---_-----------------------------------
,� Test Pit No. 1________________minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------
LT, Test Pit No. 2................minutes per inch Deptilof Test Pit.....................Plepth to ground water........................
ODescription of Soil-------------------•-•••- ,. -. • r--------------------------------------------------------------
x
U ----------------........................................................................................................................................................................................
W
V Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------------------------------•----------•----------------------------------
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 ees not to place the system in
operation until a Certificate of.Compliance has been issued by the board lth.
Si d. .__�
----------
Date
Application Approved By. -•--•-. --•--• • • ---------- �- ... ----?W
roc
Application Disapproved for the following reasons:.----•------•-••••-•-•--••-•-•-•-• ...........................................................................
......................----••---------------•----•---•-••--••.........-•------••••••-•----•••--•••---•---••----•-••••-••------------------------••----•-•••------------------••--•--------------••••••-
'a � Date
Permit No. Issued------... ---� 7/ ......
Date
No.. ......4..._---_. FEs ........................
THE COMMONWEALTH OF MASSACHUSETTS
'BOAR® �F HEALTH
,j
OF...... i
. .. �, „,_.----- -------------- --•--------------------
Appliration for 13isposa1 Workii (fromlrurtion Prrmit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
Sy
Location-Address t or Lot No.
1; `
t ��- ----------•-. ----------------------------------------------•-•--•---
'" Address
nst�ller Address
U Type of Building Size Lot_./__:�� �`° q. feet
Dwelling No. of Bedrooms-----------n ______________________Expansion.Attic ( ) Gat4ge Grinder ( )
' 1
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
d Other fixtures --- - --
_ Mons er erson er da Total dail flow______ .,a _ gallons.
-------------- ----
W Design Flow ate- P P P Y Y *��
WSeptic Tank/L Liquid capacity/r, `' llons Length_______________ Width---------------- Diameter---------------- Depth................
x Disposal Trench—No_____________________ W2�v
h___ : Total Length.................... Total leaching area-___ _-_____sq. ft.
Diameter e th below inlet_____ Total leaching area ft.
Seepage Pit.No. ---/------- P g -
Z Other Distribution box ( ) hosing tank ( )
aPercolation Test Results Performed by---------------......................................................... Date----------------------------------------
Test Pit No. 1................minutes per,inch Depth of Test Pit.................... Depth to ground water-.___-__________-___---.
44 Test Pit No. 2................minutes per inch Depth of Test Pit____________________ Depth to ground water-_-______-________-.-.-.
Description of SoiL------------------ --- 1. ----- - ---
s------------------------------- ------------------------------
U ----------------- --------------------------------------------------------•----------------------------------------•.----------------------------------------------------------------------------------
W .
-------------------=------------------------------------------------------------------------------------------------------=-----------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable..______________________--______________-_-_____-._________-____-----_-__--._.-_-.-_-._-__----
-----------------------•---------------------------_____----____-------------------------------=--------------------__-___------•-----------------------------------------•---------•-••--------------.
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 f-!yalth.
". ?,e�'r' -------� t Date
Application Approved BY--- .� Imo...: "'�, ...T -% D .
at
Application Disapproved for the following reasons-................................ ----------------------------------------------------------•----
-----•----------------=--------------•------------=-----------=----------------------•------------------------------------------------------------=-----------------------____.-------------__----------
Permit No.----- - Issued = 'l J ---Date .....
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
t
" :-' OF.... .
Tatif irate of Tomphattre
TSQ (IERTIFY, at the IndivicJ4,al Sewage Disposal System constructed 4<or Repaired ( )
by r ' ----
__ / -- "�- n jape - 17.7....
., • 't• -
., -'`
----------------------------------------------------
4.
habee i nstalled in ail i Q
at
with the provisions of Article X of The State Sanitary Code s described in-the
application for Disposal Works Construction-Permit No,___ _____,%......__` "�`
-----------_ dated-----��- ----------�� ---
r THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GU RANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-- i z Inspector ''
f ,t -•---
Yf
THE COMMONWEALTH OF MASSACHUSETTS
BOARD".OF EALTH
AP .mo-" V 1 d3`N ?il'.. .ur-`✓ .. 3 .....
.. .....,¢.... �. �� .. . OF.-.. .......
J No. .._.. , .. .. : .. .
- -- FEE
w
Permissio > hereby granted----------
..., -..-_.
to Coristru ) or Repair f{ ) an Ir avldu r,S Wage I,z �osal System
f v
----
Street j *'
as shown,on.the application for Disposal Works ,Construction Pe: No ` l_st...... .Dated___
Board of Health I DATE------------•••-•--•---------------•-----------•-•.....----••----------••----•-
FORM 1255 HOBBS &-WARREN. INC.. PUBLISHERS -