HomeMy WebLinkAbout0278 BUCKSKIN PATH - Health (2) BuCesKin Pa-�-h
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No.....;1Y.....-- Fmc...�..................
THE COMMONWEALTH OF MASSACHUSETTS
SOAR® F HEALTH - _
M�2 iai- u2.
Appliration -for Uiiipmal Norbi Tiltuitrurtion Vantit
Application is hereby made for a Permit to Construct (il� or Repair ( ) an Individual Sewage Disposal
System at:
r
= /..
ation•A dress or Lot No.
a.
. •".............. ...................•
i Ow er - Address
-------- --------- - •........ --�-� -•-... . .......... •---------------._.... ...........................................................................
Installer Address
d Type of Build* Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms---------�------•____________________Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures --------------------
---------------------------------------------------------------------------------------------------------------------------------
W Design Flow•_______-_-_--.-....�.._____ 1 ns per person per day. Total daily flow......__._�..��-------------gallons.
WSeptic Tank Liquid capacity_ ___ lons Length................ Width................ Diameter---------------- Depth._..___-__.----.
x Disposal Trench—N _____________________ Widt i...... __.-- ... tal Length..... Total leaching area....................sq. ft.
Seepage Pit No........ ......... Diameter___ Q v�__ pth below inlet..................
Total leaching area__....__..._..___sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-------------------------------------------------------------------------- Date----------------------------------------
,.-I Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water-..-_-._----.__.--._----
(i Test Pit No. 2................minutes per inch Depth of Test Pi .........
Depth to ground water------------------------
f4� a
0 Description of Soil------------------- ----:........ . ff'.'__
---------- ---
14 ZY
W --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
UNature of Repairs or Alterations—Answer when applicable.---------------------------------------------------•---_-__-_-_-_.-------.-.____--._.--__--.
------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------
Agreement: It
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordanciti
the provisions of Article \I of.the State Sanitary Code—The undersigned furt r agrees not to place the system in
operation until a Certificate of Compliance has been by the b of hea
Sie
--- -- --- -------------------------------------
..... ..
• Date
Application Approved By--..: ------
�, Dat
Application Disapproved for the following reasons------------------------------ ----- - -- --- -----------------------------------------------------------
......-----•••-----------••-•---•-.................... ------•-•-•-----•••---••--•-----•-•-•--•-•-•-----------------------••-------.._..-•-----•-•--------_..
Date
Permit No.------. Issued------•�__--< ------•---
Date
------------------------------------------------------------------------------------------------------------------------------
No...... Fus.. .... ......
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
a
41Z.-
A .
-- / ®
�/ =. .OF....... ? .�,a* .'. '................... N
Appliration -fur Biiipofi tl Works Towarurtion Vrrmit
Application is hereby made for a Permit to Construct O or.Repair ( } an Individual Sewage Disposal
System at,
Ayl
......................... ..............................
.cat o -Address ........... or Lot No..........................................
y Ow er Address
...........................................................
Installer Address
Q Type of Build* Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms---------- ...........................Expansion Attic ( ) Garbage Grinder ( )
Pk
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
d Other fixtures p.. ............. . .. .
---------
W Design Flow.. ................... .... 's......._ t�Ions per person per day. Total daily flow.........__-� ......
Design
WSeptic Tank I—Liquid capacit. Ions Length---------------- Width_---- Diameter._......._...... Depth......_.._..._.
x Disposal Trench—N9..................... Widtji.. . ..j..- �_ tal Length---.._-__----------- Total leaching area........---------_.-sq. ft.
Seepage Pit No.___---,t_-__--_.._- Diameter_-._-i --._.. below inlet.................... Total leaching area------------_.._..sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-------------------------------------------------------------------------- Date--------------------------------------..
W
Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water................-_..__..
riq Test Pit No. 2----------------minutes per inch Depth of Test P' .._ ...w_.____._... Dept to ground water-..-.......--..._._.....
------ -------------------------------------------------------------
DDescription of Soil------------------------------- _.m-------- ------------------------------.....----- ------•-----------
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 furtl�,,36 agrees not to place the system in
operation until a Certificate of Compliance has been.A.s>ti4 by the br -6of heal .
��"`t'- --arm
------------
Signed"__-" - ------
Date
Application Approved By....'' _... ...°,
Dat
Z.
Application Disapproved for the following reasons-------------•-----•-----..........--------------------------•--------------- ------.............................
------------------------------------------------------------------ ------------------•----------------------•-••----•--•-•----------•-•--•.............--------------------------.----------------------
Date
PermitNo......................................................... Issued.........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.d..:#. . .......OF..... �." a >:ap r .r�.:'.........
QW.1ertifirate of hTompiitttirr
THIS IS TO CERTIFY, That the Iijdividual Sewage Disposal System constructed ( ' or Repaired ( )
vrt.�� rat . �_ Sti
------------
rL r f Installer, { 5
-------- ------
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....._--.- .. 9'�. .............. dated...:___°...__ --------------3----•--_--
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION' SATISFACTORY.
DATE. Inspector...............................................................-------------------•
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
t ....... .. . .. ....... OF. _ .:........ .... ....... ..
No......................... FEE ---
Di_nVoiittl Workii Tomitrurtion Vrrmit
-------------#- -----�� --`==--=�--------------------------------
Permission is hereby granted_._:.__`_.._°..-_-.-_
to Construct ( or Repair ( ),an Individual Sewage Disposal System
Street f
as shown on the application for Disposal Works'Construction Permit No..' _ ` Dated.:^-_`n..--.."l` .
Board of Health
DATE------711.7- ------------ -----
FORM 12'55 HOBBS &':WA EN. INC'.. PUBLISHERS