HomeMy WebLinkAbout0193 BUCKSKIN PATH - Health (2) 193 —3f uck`S&l Tw-h
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No.... ._.. SS FrE-...:.........................
THE COMMONWEALTH OF MASSACHUSETTS Y
BOARD OF HEALTH
,,aaD4 :- -------.OF............. ............
Applirattnn for Disposal Works T.unfitrnrtiun rrutit
Application is hereby made for a Permit to ,Construct �r Repair ( ) an Individual Sewage Disposal
Syst at
1 .
-•---• -•---•-
Locatio Address N.. / •-- •-- ----------------------
____-•--
Owner Address
a .. - ........ .`-------------------------- -----------•-.....------------•-•••--•-•--------••-------•------------•----------• ..
� Installer Address s
Type of Building Size Lot---/,J__ ----er ( )
aOther—Type of Building ____________________________ No. of persons____________________________ Showers ( ) — Cafeteria ( )
Otherfixtures ---------------------------------------------------------------------------------------------
W Design Flow__________________ ____ __-_ ons per person per day. Total daily flow._____._ _ l�1-___ ------gallons.
WSeptic Tank—Liquid capacit _______._ allons Length________________ Width---------------- Diameter_______________ Depth.............
Disposal Trench— o_____________________ Width..........._ __ al Length..__._________ ____ Total leaching area--------------------sq. ft.
Seepage Pit No.____ -.--.--- Diameter./0,w_�___ De th below inlet_.___.______. Total leaching area _ . ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date----------------------------------------
a Test Pit No. 1................minutes per inch Depth of Test Pit_________.__________ Depth to ground water_..................
.--
fX4 Test Pit No. 2................min per inc Depth of Test Pit_____.__ _________ Depth to ground water____________________-__-
-----••---- - -------- --- ------ ..............------------------------------------------- -
0 Description of Soil---------- - --- ----------------------------------------------------------------------
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 fur er agrees not to place the system in
operation until a Certificate of Compliance has been iss ed by the bo of heal
Sig -�-_-•--•- -----------••-•-----•-•---------
Date '
Application Approved B l% �z f------------- -=- -=--�
PP PP y----
Application Disapproved for the following reasons:---•-•------------•-------•---------------------------•-•-----------------•---•----------------------------•--•-
•---•-•-----•---•--•-----------•---•-•---•--...---•--------------------•--------•--•---..:----------••--•..----••-•-•---------------•------•-•-••----•---------........................................
Date
PermitNo......................................................... Issued........................................................
Date
i -
No.... ._t ---- Fxx..... ....................
THE COMMONWEALTH OF MASSACHUSETTS -
BOAR® OE. HEALTH
� - . ---
----- .OF..... .... � �°
ter-=t3� - (�............
Appliration for Disposal Works Towitrnrtiou Prrmit
Application is hereby made for a Permit to„Construct : or Repair ( ) an Individual Sewage Disposal
Syst at
� f
Locatio Address '. `
0 or Lot No.
W a Owner Address
- ..... .................................
Installer Address
Type of Buildin - Size Lot__ '?----Sq. feet
Dwelling No. of Bedrooms-_____ ________________________________Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of-persons............................ Showers ( ) — Cafeteria ( )
Other fixture - -------------------------------------------- -
------ ------ - -------
W Design Flow.................t�� :__:, _ Mons per person per day. Total daily flow______. _45P77 G__-_--_-__--_-gallons.
WSeptic Tank—Liquid` capaci y� '___t gallons Length............... Width---------------- Diameter__-__.--__---_- Depth-_ _---_-------
x Disposal Trench / s%'
o...___._____ __ Width _ tal Length.___.... � .... Total leaching area------, -_sq. ft.
3 Seepage Pit No_ ________________' Diameter _: `___ Depth below inlet........ ___... Total leaching area `_ s'q. 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--------..__-__-__.____
44 Test Pit No. 2........________minpt , per inc Depth,of Test.Pit_._:___ Depth to ground water______.....__._._____._.
Description of Soil----------- . .. .. .._ •. -- -- -- - - ` .
x
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 bo of heaq(h.
> f r Date
Application Approved BY w;...... i --- ' 4 = -r, ---------- ,r _ �-- ----'�"".
f ) ate
Application Disapproved for the.following reasons-------------------------------------------------------------------------------------•-----------------------•---
--•-•------------------------------ -----------------------------------------------------------------•---=----••-•••-------••---
Date,
PermitNo......................................................... Issued----------- ...........................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
.......:......oF.... OF HEALTH
BOARD
Trrtiliratr of Tnunpliaurr
THY)S T r TIFY at the Individual,Sewage Disposal System constructed ( or Repaired ( )
b ''
Y - b �'� � = _ - -- ----
f ` � Installer F ........at , y
has been installed.in accordance with the provisions of Article XI,00f T.he State Sanitary Code describe in the
application for Disposal Works Construction' Permit No..__...._..� -- �- d 2-1
ated....�d� ._�_�:
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
'SYSTEM WILL FUNCTION SATISFACTORY:
DATE ............................................. Inspector---------=-------------------------- ...............................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD f. - F HEALT
Permission is, ereby granted__..: w - 7 = =•ter
to Const t (, or Repai ) an dtvldl ,Sewage Dtspo S '
- - --------------------------------------------
atStreet
as shown on the application for Disposal Works Construction Permit No--------------------- Dated___. .,Z:._ /. ->
o=
--------------
B
DATE.......
� .R Board�
f Health
FORM 1255 HOBBS & WARREN. INC., PUBLISi';ERSy,�?..,, VVU i/
j 1 "