HomeMy WebLinkAbout1241 BUMPS RIVER ROAD - Health (2) a�� ,���PS t2;vex �
7 -
No.....6 -... ..1... Fizz... ............../
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O , HEALTH
.........OF..............��%
01� Appliratio for Dioposal Works Towitrurtion, Pumit
or�-------�7
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at.
ti .�1... ._ -. •.•...._ _....Y
•ocati dress or Lot No.
ner Address
W
a .........•.•• ............ .. .. - - -- ------ ------------------•--------"--- -------------•--------------- .-----------------'--...--------------------••------------------
Installer Address
Q Type of Building Size Lot___________________________Sq. feet
U Dwell No.No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
p, Other iv Type of Building No. of�rso Showers ( ) — feteria ( )
Q' Other fixtures • . .........l ..?�••c-------1 .... ..e-•---
Design Flow .. •................ r -%___. lions per person per day. Total daily flow..................
WSeptic Tank d`—Liquid capacitylons Length................ Width................ Diameter............... Depth................
x Disposal Trench—No..................... Widt ........ Total Length.................... Total leaching area--- -----sq. ft.
3 Seepage Pit No______ ___________ Diameten.��l_....."Depth below inlet....... Total leaching area_ �.--_N`S-rft.
Z Other Distribution box ( ) sing tank ( )
aPercolation Test Results Performed by---------................................................................. Date-------------------------------------
,� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.-.-__--_---__-___-.---.
rZA Test Pit No. 2................minute per inch '.pth of Test Pit................._.. Depth to ground water.--___-_-__--_-___--.---
a' ---------------- -----------••--•--•--- ••-•--------••-•••••••••-••••--••----•----•-••-••-•••-•-•-••-•-•._.....••-•--•-••••......--•-------••-•---------
O Description of Soil---=---------- -_ __
v ------
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 further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed -- --- - ---- ------------------------------------------------------------- --------------------------------
e
Application Approved By---- •••••• • �//7--- - ---
e
Application Disapproved for the following reasons:-------------------- . -• . -•-•-----....------•-----•--......•--------•------•----••---••••-•••••-
••--•-....--•----------------•------••-•---------------•-----------------------------------•------------------------•-•-•-••--••-•••-...••••-••-•••---------•••••••-•--------------•••-•......---•------
Date
PermitNo.......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OAF-7HEALTHZ,
vim'` .....OF..
Appliration for Riipmal Varkg Tomitrurtion Prrutit
Application is hereby made for a Permit to Construct ( ) or,Repair ( ) an Individual Sewage Disposal
System at
a a✓ r x�T /f
T
Location'-A'`ddress} 4 or Lot No.
Owner Address
W ; -
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
p, Other Type of Building r No. of verso s ._________.:. Showers ( ) 'cafeteria ( )
Q' Other fixtures e.------
Design ° ' R
> �"
W Design Flow ___________ __ _;__ ,gallons per person per day. Total daily flow..................P�'__�' " ____ _gallons.
IxSeptic Tank __ Liquid capacityi : _:gallons Length---------_---- Width.____ --------- Diameter---------------- Depth----------------
Disposal Trench—No..................... Width___ Total Length.................... Total leaching area.-_ sq. ft.
f1. t
See a e Pit No______ ____________ Diameter Z p g 69/_j__------- Depth below inlet.......e........ Total leaching area__ _-__i_ 'S 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.--__--_--___-_---_-----
/(r Test Pit No. 2-----.----------minutp"s per inch Depth of Test Pit____________________ Depth to ground water.......................
W _________
10 Description of Soil-------------- -et �i__=% _ --•--•----------•------------------------------------------ ------------- --- -
V --------------•-----------------
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 issued by the board of health.
Signed
r
Application Approved By---- '- `" ..._(: �/ € ----- � "`" ..
Date
Application Disapproved for the following reasons_ _________ _________ __.__, .._.________.__..__._____.-__---____--_-_---------.____--.-------.-----
------------------------------•---•----------•---•----------•--------------------------•-------------------------------------'---------------------------•---------------------------------------------
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OFt
JEALTH
T rtif iratr of Tomphaurr.
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by k --- ,
- .....................................
l° f ' Installer
has been installed in accordance with the provisions of Article XI of The St to Sanitary Code as described in the
application for Disposal Works Construction Permit No________________ __ __ dated-__-- -
._ °_._ ____.__.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..............................................-------------------------------- Inspector------- ° z` � "=
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O �-IEALTFI
/� ..... :. .. .. OF--- --.g �-
No.. s FEE...
i viiat Morkii Toustrurtiun ramit
Permission is-hereby granted__ ._.__ ___ ___________.:.._-._. ................
-- ----- - -- -----
to Construct Q/`) or Repair ( ) an individual Se;w age Disposal ste
at No.--- a� ' � ' : 'y1, -` --- ----
< Street
as shown on the application for Disposal Works Construction--P'erinit No � `! ".__ Dated.--- ��_:_: _::- ........
o 'Health ............i........
Board
DATE-------------------------------------- 1 .
.- f ..
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
tr{