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HomeMy WebLinkAbout0207 CAP'N LIJAH'S ROAD - Health (2) ao7 Ca�'n �- �NlD�CI kilo �&41�0 Hoff 03"M • vAm OON ®®v W cj //® No.. ..... Fps ` ................. THE COMMONWEALTH OF MASS' CH SETTS s dq, — oq BOARD OF HEALTH ................OF....Iu�QiV v�i. Lf b'l.i. .......................................... Appliration for Mnpaaal Warkii Tonstrnrtiun ranat Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: _ L catio ddress or t No. ..... ,e..... .... ... n... ... ... ............. Addre s ice..- ------------------- ---- ........:c�,P _. J ........ '. ll� Installer Address QType of Building Size Lot----------------------------Sq. feet V Dwelling—No. of Bedrooms............................... Expansion Attic ( ) Garbage Grinder ( ) -------- aOther—Type of Building ............................ No. of persons.............................Showers ( ) — Cafeteria ( ) a' Other fixttuss ----•--•.............•......... • - W Design Flow............................................gallons per person per day. Total daily flow__-_-__-._ ..................... WSeptic Tank—Liquid capacity- WD..gallons Length-----............Width...V......... Diameter-_._.__._-__-___ Depth..... ...... x Disposal Trench—No..................... Width.................... Total Length.....//.._........... Total leaching area....................sq. ft. Seepage Pit No........I........... Diameter-&.6-_-_- Depth below inlet.., ._.._... Total leaching area....0.b..._s9. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. .....minutes per inch Depth of Test Pit.................... Depth to ground water--- 1..�.� r4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -------------------------------------- ---------• - --------•------------•-----------•......------------------------ -------------------- O Description of Soil........... �......Ai4& .. 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 T1IL LE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been isigbed by the boa of healt in --•---. .. . .. .................... .... �. ---- -----�-- Application Approved By--- -------- ------------------------------------------- ....�-- .................. Date Application Disapproved f o e owing reasons:............................................................................................................... ............................................ ---•- •••-•-----•---•--•------•--••---•-------.........-•-----•-----•----••-••----•-- --•---------•-•••--••-••--•----•-----•---••-••--•----.......-- Date Permit No...........Zi.. .-.�.�...��- ------------------- Issued......................................... --•---- Date No._ .... FE ..................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ----------------- ........................OF..................................... . ,Apure#inn for Dispas al Workii Tonstrn.rtinn Famit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at tv� L tio ddress -- o .__... a .... ....... `._ fl ................. s Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms......... ............•.............Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) Cafeteria ( ) Others ------------------------•----------------------------------------------------------------------------•-._ .....------------------------ •------------ WDesign Flow................:........................gallons per person per day. Total daily flow._..____. .....................gallons. WSeptic Tank—Liquid capacity/APO--gallons Length___- _..____ Width.:`.......... Diameter___-_----__-•__- Depth.... ........ x Disposal Trench—No..................... Width.................. Total Length p Total leaching area........ 6----- sq. ft. Seepage Pit No_______ ____ _ ____ Diameter,l�Q ._.___ Depth below inlet ?__ ......_ Total leaching area___0 _._. .s . ft. Z Other Distribution box ( ) Dosing tank ( ) J,q - ham- aPercolation Test Results Performed bY--•--•------•-•-••.=••-•••-••-•-•--•-......--•-•-......•. --• Date----------------------------------•- ,.a Test Pit No. 1-�"`:_2---____minutes per inch. Depth of Test Pit.................... Depth to ground water-__eVP1.�*... . 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........... -............ Pd O Description of Soil..........`"ate? ----- = --•-•- -----•---------•--- x U -••-•---•--•••---•-••••--•••-•-•••-•-•••----------------•••--••-••-••-•••-••••••-••-•....•••---•--•••......----••---•••......---•-- w x --•---••••-•----•-----------•------•-••--•------•-•------•-•---•••••••---------••••.......•-•••••••-------•--••------------•••--•••••----•••••----•••-•-•---•••--•••-••••------•••••......---•-----••••- 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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been 4ued by the board of healtj ApplicationApproved BY •?....... . -• ......•• ---•.....•••--•........•--••-••••............................. Date Application Disapproved f o'. a lowing reasons:............................................................................................................. Date PermitNo......................................................... Issued......................................................... Date THE COMMONWEALTH OF MASSACHUSETTS . BOARD OF HEALTH ..........................................OF..................................................................................... , Trrtifirab of TnntpliFanrr TM 'I RTIFY, That the IndLiXidu4I Sewage DIs osal System constructed ( or Repaired ( ) x by---- ....:..:.....: . ..:....... . -----... .._.. .._ ..... . ••.....••--•-----.._........._.............---•-......_................-- , `�. ---------••-_..... '_ Instal .......... r at t` has been installed in accordance with the prow sions "TIT r r of The tate Sanitary ,' in the application for Disposal Works Construction ermi No.- :. _:_ "_., _ .__.._ dated_ _!._ .: ............. THE ISSUANCE OF THIS CERTIFICATE S LL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..................... K�.................................. Inspector.-•-. ..................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ' ...OF..... v No .... ...... FEE .. .... �i� � nn��rinn rani# Permission <, ebY to •--••• • ... • ..................- ..•• •---------••--............................................................. to Construct' ' n nGi wagg o ystem Street as shown on the application for Disposal �N orks Con sy 'I n Permi ._.............. Dated.... ...` ......'_................... , Board of Health DATE......----------------------------•--.......................................... ,A 1255 FORM M. 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