HomeMy WebLinkAbout0286 BUCKSKIN PATH - Health (2) a86 &3uc�s�Ci'n Pa-f-h
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No..... � Ficim.. ,.............
THE COMMONWEALTH OF MASSACHUSETTS
ROAD® HEAL
%_14 --....OF......... ....................... . - . .-.-............ ..........
Appliration -fur Uiupuuttt Workii Tongtrurtiuu Prruid
Application is hereby made for a Permit to Construct (4""") or Repair ( ) an Individual Sewage Disposal
system - "" �. V"1. �f� !
L�10 c lion_Ad ss or Lot No.
wrier Addres�
W ........... --•- ---•-------------r-••-- ------ - • - --- ..................................................
Installer x Address
dType of Building, Size Lot----------------------------Sq. feet
U Dwelling LA1o. of Bedrooms_____________ ________-________Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building __________________________ No. of persons............................ Showers ( ) - Cafeteria ( )
Q' Other fixtures ______ _____________________
d ---------------------------------------------•----------------•••-•---•--•-------•--•_--•---_:
W Design Flow___ ________________ ___-._ gallo s per person per day. Total daily flow____._.__-- __ gallons.
WSeptic Tank Liquid capacity ._ _. ons Length.._.__.._ ______ Width........ ...... Diameter................ Depth-----__--_-----.
x Disposal Trench—`No--------------------- W/dt�._._..._.. Le otal leaching area-•-----_----------Sq. ft.
Seepage Pit No...... Diameter �_ ept beloo
a Total leaching area.--------------_..sq. it.
z Other Distributior�f box ( ) Dosing tank ( )
Percolation Test Results Performed by-------------------------------------------------------------------------- Date-------------------------- -•--•-------
,aa Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water-----------------.......
Test Pit No. 2................minutes per inch Dep of Test Pit.................... Depth to round water---------------
a -------------------- -------•--- ---• ---.._--•-- _-•-•--•---------- - •--_--_-_•---•--•• ------•-----------------_-•--•------•------------
O Description of Soil -•------------ = -- -
x
------- --------------------
W ---------------------------------------------- --------------------------------------------------------------------------------- ----- - - - ---- -----------------------------------------------
UNature of Repairs or Alterations—Answer when applicable._-..__.�,,,� A r e;
-----••--•--•--•-•----------------------------------•------••---•--------------__•----•--•---------------------•-••--•••----- -------= ---- ----- !.................-----------------'---••------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Dis sal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned furth agrees not to place the system in
operation until a Certificate of Compliance has been issued b the bo f hea
igned.-- -- ........ .....................r`... -•--------------------• -- -----------------•--•---•---•---
Date .�
Application Approved By----- " := -- ---- D ���
Application Disapproved for the following reasons:-----------------------------------------------------•-_------__--------_-----------------.___.-----.._..--___-•
_._.--•-•----••-•------•--------•••-•------------•--•-----••--•••-•--._...-••-•-••-•-----------•-•----•-----------------.............--------------- •- ...........................
`� Date
PermitNo.................---------............................... Issued..........� -- ---•(-/--------•--••--•--•--------
Date
No.... ......... Fps. ...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAL.T.p
..... .. . ........OF...... �.
oration -for Disposal Works Tontrnrtion Vrrmft
Application is hereby made for a Permit to Construct O or Repair ( ) an Individual Sewage Disposal
System�1F
- r °= a -------------------------
I oc ton Ad yess or of No.
*3�e, 1._._•...... ------------------------•------•----•-------------------
9 Xner Address
Installer Address
Q Type of Building�. Size Lot............................Sq. feet
Dwelling—Mo. of Bedrooms------------------ -------------------Expansion Attic ( ) Garbage Grinder ( )
Other=Type of Building No. of persons............................ Showers — Cafeteria
0., YP g P ( ) ( )
al Other fixtures .......
Design Flow.. .................:. ........9111 s per person per day. Total dailyflow.......... gallons.
Septic Tank Liquid capacitygr ons Length................ Width..___..:....._. •Diameter................ Depth................
xDisposal Trench—No_ ____________________ Widt i__,._______:___ __:: t L. ,,d /'Total leaching area----.---.---.---_---sq. ft.
Seepage Pit No.. ...________ Diameter- _.f,/_.'_ �a�__ ept Belo" nle`t.................... Total leaching area..----_.-.---..--sq. ft.
z Other Distributi.- box ( ) Dosing tank ( )
aPercolation Test Results Performed bY-------- --- ............... Date----------------------------------------
,4 Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water-..--------..--.--.----.
�14 Test Pit No. 2----------------minutes per inch De of Test Pit-_:_:____...__...... Depth to ground water-_.---.--__----..-_-----'
D Description of Soil----_... •.... ---� - ----- gx
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 furth�e.ragrees not to place the system in
operation until a Certificate of Compliance has been issued by the boar&—of health' .
igned --------------------------- --------------------------------
Datey
Application Approved B -_�, ge -�-- '.� f��` �-- + -a>l --
---- - - -- --- - - -
Date
Application Disapproved for the following reasons:--"---------------••----•-------•-------•--•---..........-----------------------...............................
•--•---••---•---------••--•-•-------------•-------------•---•-----•--•-----------•---------------•-----------••---•-----•-----------------------••-•---- ------•-----------•----------------------------
Date
PermitNo......................................................... Issued........................................................
- Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF......... . *............ ...
Trrtifirate of Toutplittnrr
THIS IS TO CERTIFY, That t�e Individual Sewage Disposal System constructed (4<0r Repaired ( )
s Installe 1
at........_... 14 � 1 ..........K'`=----- --- a s-- 3,._°:ab �.... .. ....... • '4. -' r �? Jul !...�. •
l
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 M ... ... ..........
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 ,
....... ...... ....... . O F.... *. 3. - - ..............................................
o.N FEE .... --•.------
Rsposal Works (nonotrurtion Prrotit
Permission is hereby granted..............1�111:t ?. ..........0 ............. ..................................................................
to Construct ( P or Repair ( ) an Indlvtdual Sewage Disposal System r,^
at No. r 2�r'' '"�a` !,_��-��j...X�%.�_t- _ :i �t f. .. .:' # _J rr"�- rs _,_"...............
.
Street
as shown on the app ication for Disposal Works Construction Permit o .._.... .__ Dated_: :_..' .__.__.
------------- Ems"' -----
t
�J Board of Health � y
DATE. / �� �a 1, -
FORM 1255 HOBBS & WAR EN. INC.. PUBLISHERS s fi. +.�'