HomeMy WebLinkAbout0234 BUCKSKIN PATH - Health (2) a3�/ Buc,�s�r'h P4f4i
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No.......... ------- F ..........v..U........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
LJL4,1w... ---.....OF....U.. /lhsy"d9......L
A1111 iration for Disposal Works Tonfitrur#ion Vanfit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
" dells/lid '4 ..:_......__CErv�ccc...
or
Location-Address .....Lot_No........................................ . ....................-------------------------------
W G G�Owner Address
Installer Address i
Type of Building Size Lot.../6-A.vUv-----Sq. feet
U Dwelling—No. of Bedrooms- _....Expansion Attic ( ) Garbage Grinder ( )
aOther—Type
of Building ____________________________ No. of persons............................ Showers ( ) Cafeteria ( )
dOther fixtures ......................................................---------...••---.._._..---------------------------------•------------••--•-•--•--•---•---•----
W Design Flow.......J�_Q.............. gallons per person per day. Total daily flow........�a ___._____..__________._..gallons.
WSeptic Tank—Liquid capacityy//--_--_______gallons Length................ Width---------------- Diameter................ Depth-----_____-_----
x Disposal Trench—No..... ._ Width-------------------- Total Length...................- Total leaching area--------------------sq. ft.
Seepage Pit No...�QQ�....... 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-_--_--__-_-__-___--_-..
PL, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------.---_--_----
Ix -•----•-•-•-----------------------------•-•--•---•-••-•-•-••••••....-----•-•-••••------•-------•---.........................................................
0 Description of Soil----------------- .................
------------------------------------------------------------------------------------------------------
U •-----------------------•--------•----- .... .............. G =------------------------------------------------------------....------------------------.----------
UW ---------------------------------------------------------------------------- ------------------------------------------------------------------- -----------------------------------------------------
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 t e board o ealth /'
Signed... ----- .r- -•••--------- �1_. "
/ Date
Application Approved By------lefulowing
--e--------------------------------------------------------------------------
Date
Application Disapproved f or t reasons--------------------------------------------------------------------------------------------Da-t.e..............
-------------------------------------------------------------------------------------•-------------•------••----•--•----------------------------------------------------------------------------------
Date
t Permit No.-------�--�'�--...'------------------•.............. Issued......................
..................................
Date
r.
No................ ------ Fix....._.....`.. ..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
s
Appliratiun for Uiipniiaf Workii Clnnitrnrtinn rrinit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
. JL .5/c'. } `may. r z�r 1 f .
Location-Address or Lot No.
J{ * Owner •^, Address
W t f ....
Installer Address
UType of Building Size Lot_________ .....Sq. feet
Dwelling—No. of Bedrooms____ ___________________________________Expansion Attic ( ) Garbage Grinder ( )
`4 Other—Type of Building ______________ No. of persons--.__._._____..___..____._._ Showers — Cafeteria
� Other fixtures -------------------------•--------------------_--------------------------••--••-------•--•-------- ----------------•---••-
Design Flow.......y, �_ ----
_-----__ _..........gallons per person per day. Total daily flow........-1 eJ___._.-___._________.__gallons.
Septic Tank--Liquid capacity_._.._______gallons Length---------------- Width---------------- Diameter___.._-.-__.-_._ Depth-------------_-
DisposalW Trench—No._.____._._%F Width____________________ Total Length Total leaching area.____-_.____-__: ft.
�.�-----• g g � ----sq•
3 Seepage Pit No..__?!fj`£a_______ 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-.---.-_--__--.-_---.--.
Test Pit No. 2.............___minutes per inch Depth of Test Pit.................... Depth to ground water........................
-----------------------------------------------------------------------------------------•---•-•--.........................................................
0 Description of Soil-------------------------- •----------------------------------------------------------------------------------------------------
V _'s
y' -
W
UNature 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 issulte board cp#Oealth
/r d' (�f h
• t
' Signed.....�.�._.a,�:':.t_:. �`_���t �'' __: ��'-���t�?'-.'t��_---•- --{ —Z S ��� ^
Date
Application Approved By-------------?_.__Z<----
1_. Date
Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------------------------
......-•--••••••-•---------------•••••-••••--•••----------•••-•--•----------•-•-•--••.....----•-••-•----------------••••••-•-•-•••-••••--------•--------•••••-------------•---------------------------
Date
PermitNo. -----••-•-------•-••-••--•---•--•-•--------- Issued.........:.__: ---------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
/may BOARD OF HEALTH
I1
..................... OF......... .:.. ....• ..............€ ............................................
wrrtifiratr of Tome aurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
b
// ............
t Installer
a't--------•-----dP t r•f' •- -�-fv ,✓�9 �: ,''j1 ..?'.,{J Cv a t .+{ , 'r .r,'.,Y
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No........'' --------------------------- dated--_-" _. y._ �
_ .__ ________________
,
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION .SATISFACTORY.
DATE----•-------..�/ .--. ..--------•-.._...-•----------------- Inspector---- 1---•-_ ------_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
v j ...F � s.:-.wr..............OF.........._ %ar sa ,sr },rr�sA FEE r
No.•.... •- ...............
DOVnfia nrk,i Cnnntrnrtion Vernift
Permission is hereby granted......_'''._` ______'___ :._ _ ':=__
----- ----- - --------•--------•----------------------
to Construct C' or Repair ( ) an Individual Sewage Disposal System
at No.
G+11 ................
Street
as shown on the application for Disposal Works Construction Permit No------ ',f_________ Dated____-�':_-----,} i;
........................................................... ...........................................
Board of Health
DATE..........................................>......................................
a
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS '