HomeMy WebLinkAbout0079 CAMP OPECHEE ROAD - Health (2) f ��I C"p Ol-e4er 12c9 . ,
aio /ao3�oa-L
J
No.........! ..._.<.... . ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® F• HEALTH
�..............OF..... ............................. .....................................
Appliration for Diopoii al Workii Tontrnrtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair (a Individual Sewage Disposal
System a • O
.. - - .._....��----------- -�'�yc'�---- - --•------------- ---.
.... .k jation 7 ddddress T. or I of No.
• :---••------ r• ••_ .............................. ................................................................... ........
Owner Address
W G� ..... ........••--•---••-----•••--•-•-••. -----•-----............_...._......___•----
�-� ----• •-••--- -
Installer Address
UType of Building Size Lot............................Sq. feet
., Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
per, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ............................... . .
W Design Flow...............................-------------gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity........---.gallons Length................ Width................ Diameter--.............. Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No-_---_------------- Diameter............--...--. Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by................................-......................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
....................................................................................................................................................
0 Description of ---- - --------------- ------------------------------------------------------------------------------------------------
W
c, - -----•---------------•.....---••••••-••-••--•----•-••-•---•••--•-•---•----•----••-•-••••-...-••---•---•---•-------•••-•-•-
x --••••••-•-•------------•----------•=----••••---•-•---•--•-•-------••--......--•-••-•••-------=----•----------••----•---••---------------•-----......
U Nature of Repairs or Alterations—Answer when applicable...--./_�-o w` ` G
----------------------- ------.
.---------- ....................--------- ----•--------------•---------------..----------....-----•------------•-••••••---••-••--••-• •-•---••----•......•-- "------........--•-•=•--
Agreemet: •
The' undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bft7i issued the board of health. /
1 7
Signed- ....1�------- v
t
Date
ApplicationApproved By--•---••--------•----•--•--•-------------------•-----........_•---...................._••••.---•- ........................................
a't Date
Application Disapproved for the following reasons---------------------------------------------------------------•-...............................................
Date
Permit No.......................................................... Issued_......C�-- 7 e-
Dat
No&-Y---
THE COMMONWEALTH OF MASSACHUSETTS
, _- BOARD ,OF HEALTH
G_ ( c- y`...--".------..OF..:: ..:.:r.. .....:.-
r�1irttf ou fear j3hiposal ,ark, Tonstrurtinn Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair (L„ -an Individual Sewage Disposal
System at• ,
u
ocation-Address or Lot No.
.... Yr ..... x. .. �1 :a.f_.. .........-
caner Address
........... ---------- re E._4--------------- ------------ ---------______-_------ _______ ---------------------------------------
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
a Other—T e of Building a yp g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
d Other fixtures
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No_ .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'-, Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. i................minutes per inch Depth of Test Pit.................... Depth to ground water........................
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Ri ..........................................................
---• --••••------_--- ...._.. _--•-- ................................................................................................
QDescription of Soil_ 7 , *rr'` ----` `:..._ 'o' e -----•------------------------•--------•--------•-------------------------------•-•------•--•-
x
V .......................••--•••--------•---------------•---•-•••••••• ------------------------------------------------------------- ----------------------•---------•••------------
-----•------------------------------------------------------------------------•-----------------------------•----
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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b � issued b the board of health.
Signed
^'� Date
ApplicationApproved By.........................................................................-------........_..-----
Date
Application Disapproved for the following reasons-----------------•-•, -----...------------•••••-••-----•••-•------•••-•••--------•••--•----•••-•------..._.._.._
DatePermit No-----------------------------•--•----•------------------. S Issued-� -- -•--...... ....................
D
THE COMMONWEALTH OF MASSACHUSETTS
••^ BOARD F HEALTH
............OF....
....................................................................
�rr#ifirtt#r laf ft�nut��i�nrr
TkHS IS TO ERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by �°% - -- ----.. .---- ---------••-•••_..... ................................ ------•-------------•---
------
,
-- i I� ller ---------------•- ..................................................
has been installed in acYOrdance lth the provisions of TITLE. 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit'No.......................................... dated................................................
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
No.........................
FEE ...............
S
ork
onstrudion "pamit 0r
Permission is hereby granted ~'= t�' '"f� = --- ----- ---
to Cons (Cor Repair ( Individ 1 Sewage s dal System
at No.. , ----•---- ....
------__., - 1_
Street / d
as shown on the application for Disposal Works Construction P it N. _.__ ..... Dated_f_� ...........
`B w.
oard of Hea t "'h �= B
DATE---•�� �4.
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS �ti�
r �
4