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HomeMy WebLinkAbout0032 CAP'N LIJAH'S ROAD - Health (2) 3 oZ �' 'n Liaiti.� � Cn�- ��� /�� - - - - \ --- - f _- No......................... Flxs........................... _ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH a o J ------- OF..... -at/.'" l '.4............. AVV iraliuu -fur Bhipuutti Worbi Tuuutrurtiuu Punift Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal .L System at: -1.�.. ...................... .' ��� : L `' Address or Lot No. j� Owner Address J Installer Address e Q Type of Building Size `�'.....Sq. feet Dwelling—No. of Bedrooms--------------`_--------________---_---__.Expansion Att' . ( ) Garbage Grinder ( ) `1 Other—Type e of Building �'Q, yp g�_.._�'�C�!�'•�,,� No. of persons______________ _____________ Showers ( ) — Cafeteria ( ) Q' Other fixtures _--..--__________________________ W Design Flow----------------�te.. ................gallons per person per day. Total daily flow---------------�� ---..-..-.---gallons. WSeptic Tank—Liquid capacitu.o."' -gallons Length................ Width................ Diameter----------...... Depth.--._-.--.----. x Disposal Trench—No..................... Width-------------------- Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No------------1.... Dia eter....: '_�____ Depth below inlet.................... Total leaching area.___..-.-_._---___sq. ft. z Other Distribution box ( Dosing tank ( ) 0,li, 104r -- =12"74' Percolation Test Results Performed bY-------- -------------------------------------------- .................... Date------------------------. ------------- ,� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water...----------.--_.-.-.-. �14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water.-.------__-----___-.-.. ._..... TY - ` - �.� _ il ODescription of So -- ------------------------------------------------------------- ------- ' ------------- ------------------------ ----------------------------------------------------------------------------------------------•--------------------------------------------------- .............. V 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 \I of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss the board of healt Signed `' "� ---- _- --•- �'---- Application .� i� ate ' Aroved B /' - ------------------------- - ------ ..... ----=----- PP Y------- - -'�-�- - - -- Date.. Application Disapproved for the following reasons: . •-••.... .=....._,....------. ---•-•---.....-•--•------••----••----....--•-•--------------••------------•-•-•-•---•--••-----•-•-----------_.---------------------•---------------------------•-------------------------------------- Date PermitNo......................................................... Issued........................................................ Date — ------- --- -- - r, No......................... Finc.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD �OF HEALTH / Applira#ion -fur Bi,gvuuttl urk� Cnua��#r�tr#iuYt rru�i# Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: .................... .................. ..................................................................................... ,r Lo� Address or Lot No. -•--••••-•- • 7 ------.................................................................. Or wne ©� Address ------------------------- Installer Address Type of Building Size Lot_--------`+� _-- --Sq. feet a Dwelling—No. of Bedrooms___________________________ _______-__-Expansion Atti ) Garbage Grinder ( ) t�i..< p.., Other—Type of Building !_.--j____________________�No. of persons------------------------- Showers ( ) — Cafeteria ( ) Otherfixtures ....-------------------------------------------------- w Design Flow-------------------------------------------- per person per day. Total daily flow............. WSeptic Tank—Liquid capacitygallons Liti-th---------------- Width......-......... Diameter-----........... Depth.-_-______---- x Disposal Trench—No. ___ ______________ \Vidth.__..._.__________ Total Length.................... Total leaching area-------------.------sq. ft. Seepage Pit No-------------J.. D' eter.......... Depth belowvi�,t__�JG./�-,Total leaching area------------------ ft. Z Other Distribution box ( 'f Dosing tank ( ) J- /.2 w.76 Percolation Test Results Performed by------------------------- ................................................ Date........... --------•----- ------------ Test Pit No. 1................minutes per inch Depth of "Pest Pit-................... Depth to ground water........................ (7, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_..__-_--___________---. -•------------ ------------•............................................................................................................................... 0 Description of Soil__--_-- -_•`_-_- - - � �-- -G_r_ V �., - y2 ---- -- ---- V 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 YI of the State Sanitary Code—TDhg undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss he board,ofr} alt�_�� Signed------............- � S /e* ••�� ------.. .. --------- Application Application Approved BY_ ` �� / y ? ---------- "�v/ 'DdteCi Application Disapproved for the following reasons:...._------------- -----------•--------•-•-------------•-•-----•-•-•---------_________---_-___--------- ----••••••---•--------••------------•--------•-----------•---------------•--•---------------•--------•---•---------•---------------••--•-----------------•-----•--•--•---------••---------•------------- Date PermitNo--------------------------------------------------------- Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . .... .. .. . . ............ Carr#if ire#r u um� i�tnre - -- TNS I TO C�12TIFY, I at the Individual Sewage Disposal System constructed er Repaired ( ) byr. • ---••- XI at_--=�__/.. •/!_. ._ __ ._-- ---Inst 'gr - -f- - - -- - --• -- has been ms�ailed in accordance with the provisions of Art'i e I of " ifie e Sanitary oc(eais s r m application for Disposal Works Construction Permit No0_;0 ___ _ _ ________________ dated_-___ ___..� - __________________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A AA RANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........... 0. -• P Inspector-•- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No. 2 a 5 FEE. ----•-.--:.-- Dinputittl urk,q Qlu #rur#ion errant Permission is hereby granted------ r tom_ C- -- r' - - ---- .....- to ••----•-------------------------- --------•-•---•--•------••••••-----_---.. to Constr �or . air ( ' ) n I tdatal &,age Disposal System at No. • -=---�-`--- f If \ Street ... as shown on the application for Disposal orks Construction Pe - No. __._._ Dated---- .... -.................... Board of Hea h DATE FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ire' •r _ l j1' G r� -C� F1 ��. �•� 'tea,Y . z o r-,j L - 72 G � l SILL fLE1✓______ FELT 48DVE PO.QD RL O T" FL A /\/ S C A L E -'- --�IU Z OA T& OL.AN 3 X:f fir _2'7 4, ;-1 N Of GE E T NLk?E8Y CLQTiFY-r"AT TyL LXIST- �, /N& FOUNDAT/ON LOCAT/aN /-'0-IZe4 u Z .4S SHOWN AND -CONFOQM WJT1-/ 4 1STEE-1p� THE OU/LD/,/6 SETl3ACC'PE.�U/PEM /! SL1 OF TObVNd Na, 7'��11L2T,4s` - ------• . QEL&. 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