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HomeMy WebLinkAbout0062 CAP'N LIJAH'S ROAD - Health (2) L ja-A CaJ �� I g z No. ._..... ' Fic$........��1.............. THE LTH IyI ��Z r__B.OARDAOF FHEALTHTS - _._.✓... OF........... . ApplirFatiuu lot 13iiiviaitt1 Works Tuustrurfiuu Prruid 0? Application is hereb made for a Permit to Construct or Repair an Individual Sewage Disposal PP Y ( ) P ( ) a P S st at - -V Locatio dream-� or Isot No. ner r ddress (� ® � ... ...................... Installer Address _ ) QType of Building r Size Lot .._..`.`.('_.__�Sq. feet Dwelling—No. of Bedrooms._ p ( O Carba e Grinder -•-•----•--------..._Ex Expansion A�ttc x ( g aOther—Type of Building_- .e°l<C�_' No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures --•-------------------------•------------------------------------------•-------------------------------- Desi n Flow.............. gallons per person per day. Total daily flow.._....... .- -�-.-______._..___--.gallons. W g ��------------------g� P P P Y Y g< WSeptic Tank—Liquid capacity_�OQ.©`gallons Lepgth---------------- Width................ Diameter................ Depth.__.-_.--.-.._.. x Disposal Trench—No.__._ -----_- Width.... -------- Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No........../------- Diameter-_---.4F A_ Depth below inlet......... Total leaching area.-__.-___-_._-._.sq. ft. Z Other Distribution box ( ) Dosing tank aPercolation Test Results Performed bY.......................................................................... Date--------------------------- ----------- a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water._-._---.--_--._-....__. G% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water._.-. --_---.-_----.._. - v a -- ...............-------------- ------ ---------/--- O Description of Soil-------- y..........................-......------ ---------- w = = ---------------- - '' VNature of Repairs or Alterations—Answer when applicable--------------------------------------------------..............----------- .--_-__-___.. ----------------•--------_--_..----------------------•-•-----•---•------••-•---•--•-•----•--------------•---------------•-------------------•---------_.-----------------•--------------------... Agreement: The undersigned agrees to install the aforedescribed In ial Sewage�ier posal S tem in accordance with the provisions of Article XI of the State Sanitary Code— e u ersigne ur a snot to place the system in operation until a Certificate of Compliance has been iss e boar of e t �� _ Sigd-------- --- - - -----• ...~---•----- ----=�'�`--��`---------- - � - D to Application Approved BY----- - --_ lam -- ----- '� .----- :�-. - !/ Date Application Disapproved for the following reasons________________________________________________________________ --------------------•----- -------------- ..............•-•••.•-•-•.------------------..----•.•----'---•....-----'.•-'--------•----------------._.... Date PermitNo......................................................... Issued........................................................ Date --_-------------------------------- -- -----------------------------_-____--_Y No......................... Fim....... . ..... THE COMMONWEALTH OF MASSACHUSETTS �,,_,. -RDARD OF, HEALTH .....OF...........� '� r� -...................... 1..../........ Appliratiun -fur UiopuoFal Workii Tonotrurtion Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal S4 / __ ..............._____�__........_... y c'/ Y ___ ...... ........... Location- dres or bot Aio. ner. • /Address W Y _ Installer Address U Type of Building 6vcE �-- YP g Size Lot_ .......------.-----r'Sq. feet �-, Dwelling—No. of Bedrooms............................................Expansion A .tc (?��/U arbage Grinder WO aOther—Type of Building P��!f`_' No. of persons..______.. ........._. Showers ( ) — Cafeteria ( ) dOther fixtures ----• ---------------••--•----•--.----------•------ �.. W Design Flow________________a U•........______.._gallons per person per day. Total daily flow_____......--' .`...._...__...._.._.gallons. WSeptic Tank—Liquid capacity/! gallons Lerjgth---------------- Width-------......... Diameter................ Depth.__--.--_.--_- x Disposal Trench—No- -----?`........ Width-_-_�`_-_---- Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No.........X...... Diameter-------r':A Depth below inlet_----___,�_}� --- Total leaching area----.__ ..........sq. it. z Other Distribution box ( ) Dosing tank ( ) of- /0 C — 3-3- 7G a 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...--._..-_---_--.-_---. --------------- O u G i.. $ _..._., Description of Soil- �/ /-•.. .......................... = �� - - • _= --7 ....... a.. L---- - -----�..�-�_.- ---� ------- 4 � ---------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable..---------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------•----------.--.--•-.-------------------•--.------------------------.--------- --------- Agreement: The undersigned agrees to install the aforedescribed_Indiz-it tal Sewage posaI S tem in accordance with the provisions of Article XI of the State Sanitary Code— -Ke Unde6signe ur��i err Pa s not to place the system in operation until a Certificate of Compliance has been issu r,the`board of he t11 Sid.._... -�-- '•-r-- --w-s--- �.. ---�----�- ir � _ r D to Application Approved BY------- ------- -----Y--------�----- i --------Dat-e-----------�---- Application Disapproved for the following reasons:----•---------•-•-•--------------•--- --•-•---------------•-••-------------••-----------•-----•---•------- ....--•--• ••-----•-•-----------------------------------------••-------------•-------•----•--•------••--------•--•---------•----------•-----------------•---•------------.-----••--•------------------- Date PermitNo......................................................... Issued........................ ------........................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD�S' HEALTH ..........O F. � ............................C.�..(........................ �rrtifiratr of TOntpli�anrr THIS_,I- CER"IIFY, at the Individual Sewage Disposal System constructed ( or Repaired ( ) by a_6_ 1 ..._.. ------fG_ �' =-- ----- --- / - /�/� at. !/ C/ has been installed in accordance with the provisions of A is e XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No. _._.r2_.,7_4.............. ................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........ 7....../------ ------•---------------------- Inspector-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .W ............ .. .. ........... ................................. ....._... ......... .2 ........... .............. N ......... FEE--/e......• .---- Dinpolittl Ton- rnrtion Prrud Permission is hereb granted_._.`.._ exaZ7,06A.... !' ..._.___ ------ . .••--------------------•-------•••......--•----•--•••.--... to Construct or R it ( ) an Individ 1 Sewag s st at No....- v!q!. Street as shown on the application for Disposal Works Construction Per o.._._. ated------------------------------------------ ., :--------•---------------- oard of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS sl ttT r :3T • zaIQE '72 c � 4S11Oi�,fity /fv �LA� r3c �AR OFS f (• _ - JWr '; : t ,�.� �. /NG FOU.r✓DA7%dN LdC4T/Ord %5�.�'� �.:, , '� � `` Y, , ' . • " • .q,� S�'rorV•u4.4�vt3 � �cov,�o��-rYir t Yi {�Jy� t - --.,, - ._ ti.'�r...bd'.^a � .'T. f•'�:.+T�,wS,...t=�� s.. .,. r. fcti 4`t_ .,...W, .�. .< i_ � _ .. .. 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