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Home My WebLink About0205 BUCKSKIN PATH - Health a?05 3YC Klsk"-((1 Czn4P.r ✓i t�L No.. ........ F Fimic ................... THE COMMONWEALTH OF MASSACHUSETTS BOARD HEAL H ---- --- M "CIS Appluatiun for UWpooat Works Toustrurtgon Pumit Application is hereby made for a Permit to Construct (/-) or Repair ( ) an Individual Sewage Disposal \` system Location- ress . ----- ----- ---or Lot...o. _..-- b� •----: ocati---- . . - --- ------------• -• -- ------------------------------- w Address r. -- - ------------- ------------- - Installer Address _ UType of BuildT' g/- Size Lot.- -- �..Sq. feet DwellineV No. of Bedrooms.........................----------------------Expansion Attic ( ) bage Grinder ( ) Other—Type of Building _________________--------- No. of persons......................... Showers ( ) — Cafeteria ( ) d Other fixtures ------- -------------------------- Designw Flow ... dons per person per day. Total daily flow -& gallons. C� — — WSeptic Tank Liquid capacity/4 _ .._ Ions Length................ Width---------....... Diameter---------------- Depth___._________... x Disposal Trench—.No..................... Wid h.___.__.. Total Length-----------,........ Total leaching area ___..__-- --------- sq. ft. Seepage Pit No.�__-------------- Diameter�0W-_.-•___. Depth below inlet....__6......_ Total leaching area_��`�-sq. ft. Z Other Distributi6n box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date---------------------------------------- Test Pit No. 1................minutes per inch - Depth of Test Pit.................... Depth to ground water------------------------ 1:14 Test Pit No. 2........:.......minutes per inch Depth of Test Pit___............___.. Depth to gr nd water....._--___________._._. ----- . . . • ........ O Description of Soil ....... ---. • ................................. -- -- -------- --------- -•••-------- x w VNature 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 ier agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of h h. Siz -•-----•-- -- Date Application Approved B S� f / a Application Disapproved for the following reasons:---•---•--------------•--------------/----------•---•------------•-•------•-----------•----------------•------- ----------•••---•---•---•-•-•------••----•-•...-•••--------------•....-•-----••--------•. •-•••••....-------------------•-•------------------••--•-----•---•---•--------•--•------•----------•---•- Date PermitNo.........------•----•--................................ Issued........................................................ Date . . era. E� No... � -------- Fig:iz t................... THE COMMONWEALTH OF MASSACHUSETTS BOARD Or HEALTH ....� '.......OF...... �� _' °_( e .. a. Appliration for %iVosaf Works Tonstrurtion Prrnfit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System t aI . d < qq�d 9N �, .._.�. "f{ .._. -.rJ rY::a�""'�..____. _ y14_'k ''�-��" _... s. +, � ._ 'd�` ' ......................................... Location 'ddress or Lot No. �. --- - I d,�;er Address Installer Address d Type of Build}ng, Size Lot.. _ _ �___...__Sq. feet . U � f-I Dwelling No. of Bedrooms_________________ __,_._________________Expansion Attic .( ) rbage Grinder ( ) a Other-Type of Building _____._____________________ No. of persons--------------- ........... Showers ( ) — Cafeteria ( ) Other lixtures W Design Flow _ _____:-' :_eons per person per day. Total daily flow.... x gallo ns. WSeptic Tank Liquid capacity ' a ons Length________________ Width__---__-. -_-. Diameter__.._ ----_____ Depth.....-.._.... . x Disposal Trench—No .................... Width___ � _ Total Length________ Total leaching are --- --------sq. ft. 3 Seepage Pit NoX_____________ Diameter._ ✓_ _ De � ft. , `___ pth below inlet_._.__.______. Total leaching area.. .. .......... 1. Z Other-Distribution box ( ) Dosing tank ( ) . aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit____________________ Depth to ground water--.._._-_______-_-_.--. G:.I Test Pit No. 2________________minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ ....................... .......J0. ....... ........... O --: r Description of Soil--------------------------- �. ' " -•-•--- -- - ------ ---------------- ----------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 issu d by the board of heath. Sig d =- �'�•----•- -----�-•---- � .�`-" �---•-• -- ------------------ -- -•- .✓ a �' e''° Date or Application Approved By------ .-AS'L...I_'. -7............ Application Disapproved for the following reasons- --------=----•------------------------••-•-----------•------•-••--.----------{--------------•----•••--------- ----------------------- ----------- Date PermitNo...........................----------------------------- Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL-T.H.. ........... ..........OF......... .. ... .... :........... 'Tirtifiratr oaf Ton' tp iattre TH IS Ti ,.RTIF aat the I ividual Sewage Disposal System constructed ( ) or Repaired ( ) --------- -------------------------------------- - ry� Installer F i has been installed in accordance with the provisions of Article XI of The State Sanitary Code a---- descr ed i the application for Disposal Works Construction Permit No----- ^ �_ w___________________ dated..-.-;�---�-� �"'____ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACT®RY. DATE-------------------•--•--•--•-------•---------------- ---------------•-----•---. Inspector_..=-- ----- •` "InO THE COMMONWEALTH OF MASSACHUSETTS r` NO. -� FEE___ __ , i or �trttla� prtit Permission hn� ereby granted_____ :,_p __ ._ 41 r-•-----•••-•-•----------------- to Const ct or Rep r? ( ) an lividual�Sage D posal System14 1 Street as shown on the application for Disposal Works Constructio> Pcr�11t NoJ .......... Dated - �f �• _ PP P ,✓J(( .. 1 j { DATE.•--- = o ealt B and of'.H I FORM 1255 HOBBS & WAP.REN. INC., PUBLISHERS v