HomeMy WebLinkAbout0047 CAP'N LIJAH'S ROAD - Health (2) q7 CAph (.�j&4, Cast .
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No....... �......... FE.......A...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH ,
.............0F.. .....ec/1 v�/ .... ...................
Appliration -fur Mapouttl urkii Tonstrurtiuu Vrrmit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System
—�r
LocionJadsoss or Lot No.
O Address er7 �....
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms----------- Attic ( ) Garbage Grinder ( )
aOther—Type of Building --------------- _--__ No. of persons...-------- Showers ( ) — Cafeteria ( )
G4 Other fixtures ------------•-•--•-----------------•------------------ ------
W Design Flow______________-...___.__..._.........gallons per person per day. Total daily flow....._.0 .____--__--..._._-._-._--gallons.
9 Septic Tank—Liquid capacity------------gallons Length................ Width.........-------- Diameter___-_--_.----_ Depth-.--------------
--Disposal Trench—No. _--_--__----__-___- Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft.
Seepage Pit No........l_------- Diameter.....��?'` Depth below inlet.................... Total leaching area-----------------_sq. ft.
z Other Distribution box ( ) Dosing tank ( )
`-, Percolation Test Results Performed by--------------_- -----.-_.--•---------------------------•---------------- Date---•-•----•-•----------•--•------
W f -;
Test Pit No... 1________________minutes per inch Depth of Test Pit.................... Depth to ground water._.._..__......__.:°._.
G14 Test Pit No 2__..............minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
-------------------O Description of:Soil---------------------------------------------------------------------------------------------------------------------------------------------------------------•--------
x
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 further agrees not to place the system in
operation until a Certificate of Compliance has been is y the boar e
Signed---•• -------------------•--------.......-•`e �.��---------•-----•--- •-••� �----
J
Application Approved B ate
Date
Application Disapproved fort following reasons: ------------------•-
--------------------------•---...------•---•-•--...------
_Date
Permit No......15 3_6--------•••-------------•--•-••-------.. Issued......./_ a _.t----7-)------•-------
Date
No.----.--G�3 F�$..... (t................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_........ ._.. ... . ._..... OF.
Appliratintt -fur Bhi usttl Works Zsttstrurtistt Vrrulft
Application is hereby made for a Permit to Construct ( r Repair ( ) an Individual Sewage Disposal
System/at:
l�....... j.. ; ..
/ Location-Adda+ess or Lot No.
j O er ......._..
Address
.
. ------------
Installer Address
d Type of Building ZSize Lot----------------------------Sq. feet
aDwelling—No. of Bedrooms-:-----------3__:..........--------------Expansion Attic ( ) Garbage Grinder ( )
pa Other—Type of Building ............................ No. of persons--------:'__�__-_-_------_- Showers ( ) — Cafeteria ( )
0.' Other fixtures ------------•-----------•--------•--d ------.-------------------------------------------•-•---------------•----------------
W Design Flow..............
. 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 ( )
a Percolation Test.Results Performed bY-==-'=_,;.,.-------------•-.........__................-•-•------•---..... Date-.---_---------------------------------
,� Test Pit No. 1----------------minutes per inch Depth of "lest Pit..................... Depth to ground water.._-__----__-_.-_.__...
LT, Test Pit No. 2_._'::..:,..._._minutes per inch Depth of. Test Pit____________________ Depth to ground water----------------------
------------------- ...................... ...............................................................................................................
0 Description,of Soil--------------------------------------------------------------------------------------------------------------------------.-----------------------------------------------
x
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 issx-d'by the board-of-health.
c
Signed :>��
-------------------
Gr- / Date r
A lication Approved B / //_ _=: /S
PP PP Y -- -- --- ----- -------------------------------------------------------------------------- - ----------•-•.
Date
Application Disapproved for b; e following reasons_---------------------------------------------_----------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------•--•---------------------.----_------•----------------.-----------------
�.
� Date
Permit No. � f • Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........... .............O F. . .. .... ... ...
Trrtifiratr of 101.1,IImpliaurr
THIS IS TO (7ER IFY, That the Individual Sewage..Disposal System.constructed (X ) or Repaired ( )
by.............G .•••.`- ._-------«'`"%- L
Install
at................Aopw -A--------—--------_-----......................................
has been installed i[t accordance'with the prpvisiott$mof :article XI of The State Sanitary Code as described in the
application for Disposal Works:Construction Permit N L�3_G o...-_._ ..................... dated.- _--_. -_'�_ ___7 ....
I THE ISSUANCE �F THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�Gi�lt OF.......�ft�s...S oU
No.--/ FEE---
�i>��ssttl grk� �nttstrttrtistt - i ,
Permission is hereby granted------- --- . :m...
to Construct or Repair ( ) an Individual Sewage Disposal System
at No:= -----t"---� ....... Z_ ------( -/ ..T......----G!Tip/7.------. -------.
Street
as shown on the application for Disposal Works Construction Permit No------v34----- Dated.... �_ _�
.....................��.�...`........... {..... • Board of
s► A r
DATE -- ....�..._...
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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