HomeMy WebLinkAbout0350 CAP'N LIJAH'S ROAD - Health (2) Ca 'r)
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No:..��.. ... Fas.. (d.....
N ' THE COMMONWEALTH OF MASSACHUSETTS
� 9I BOAR® Of HE&L- H
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Appliration -for Di!iVaiitt1 Ovrkii Tomi#ru ion Pumit
Application is hereby made for a Permit Yto Construct ( ) or Repair ( ) an Individual Sewage Disposal
yst at: /
��I �• ... I _,/�0044 �rl\�--- ----- Y... ............ ..---. ......._..._..................__.._.......__.............___
r L a ion-Address or of N
Owner ddress pzss
------------------------
Installer Address
U Type of Building Size Lot_1�f�'q__ _.Sq. feet
Dwelling—No. of Bedroomss------- -----------------------------------Expansion Attic ( ) Garbage Grinder
PL4 Other—Type of Building f 2g -------- No. of persons.--___r__................. Showers ( ) — Cafeteria
Q' Other fixtures --------------------------------
W Design Flow...........1..a.........................gallons per person per day. Total daily flow---------d oo_--________-..-..-.---gallons.
USeptic Tank—Liquid capacity*'�'P�q---gallons Length................ Width................ Diameter---------------- Depth.---__--_-_---
xDisposal Trench—No- ------- Wid i................ Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No/d.09? Diamete�h �- e66epth below let... _ .. otal leaching :�ev._ --------sq. ft.
Z Other Distribution box ( ) Dosing tank
Percolation Test Results ( Performed by-------------------------------------------------------------------------- Date-----_---------------------------------
Tp• .
Test Pit No. 1 __ mtnutes per inch Depth of Test Pit____________________ Depth to ground water........................
LL, Test Pit N.. ................minutes per in h D of Test Pit.----- ------------. epth �toA�gr water..........
O
Description of Soil---------------�Kw 1;�------- Z= ----- 1;;-
U ------------------------------------------------•------•--------------------•----------------------------------------•----------------------• .................................................------
W --------------------------------------- ----------------------------------------------------------------------------------------------------:----------------------------------•------•------•-----•-
U.., -Nature of Repairs.or Alterations—Answer when applicable---------------------------------------------------------------------------------------------
-- .-..
Agreement:The undersigned agrees to in 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 ed by the boar alth.
Si
_ Date
Application Approved BY ------••--•• .. -------•--- n` ---�.`. -1KY __
Date
Application Disapproved for the
he following reasons-------------------------- -- ----------_-------------•-------..__._............_._.._._......---•--------_----
..........--•---------------------•-•-•-----------------------•----......--•-•-•---•-------------------------•-•-------------------._................ .-•-•-•-- -----•-----------•------•----•-•-
Date
PermitNo......................................................... Issued.--- ---f ---- ---�.. .................
Datf
_ _. ���.�..��..��..�.�.�.�. �.���._�__•�____ -1----------------
tip. j
No._.. ... FEE` ..�......`..
THE COMMONWEALTH OF MASSACHUSETTS =x
BOARD O HEAL H
C�fi±�".........OF........... :..-
ApplirFation -for Dii oiiFal Workii Towitrurtioaa Vrrmft
Application is hereby made for a Permit to Construct ( ) or Repair (` ) an Individual Sewage Disposal
st at:
. Lion-Address Q 2 /. or t N
Owner �ddress /
� • Installer Address �
UType of Building Size Lot----- :. ----__ `_�Sq. feet
Dwelling—No. of Bedrooms___ .._...................:...__•-Expansion Attic ( ) Garbage Grinder
Other—Type of Bedrooms ......... No. of persons------"___________________ Showers ( ) — Cafeteria ( )
Other .fixtures --------------------------------------------
W Design Flow......... ______________________-gallons per person per day. Total daily flow.........S��•_________-_.-.-.--.....gallons.
fW Septic Tank—Liquid capacit��' a---gallons Length---------------- Width................ Diameter-----........... Depth...............
s x Disposal Trench—No._______-•- -•.__- Wid I._.___:_:.....__ Total Length_.____... ---------- Total leaching area--------------------sq. ft.
� Seepage Pit No%13_CJ.�?_�'..�'�Diamete __.l^t�t°_r�`�epth below ' let....__ _ - _ otal leaching area -
/ It.
z Other Distribution box ( ) Dosing tank __.__..._.sc1.
aPercolation Test Results * Performed by......................................................------------------- Date----•----------------._.----------------
Test Pit No. 1___. minutes per inch Depth of Test Pit.................... Depth to ground water-.......................
f14 Test Pit N . -:_-•___-_______mnxttes r in
h D of Test Pit______ _______ ____ epth t r wa_t�i
g
Description of Soil-----------
U -•---------------------•-••--------------------------. .................. = ---•••.....................................................................................
x -------------------------- --------------=--------------------------- ----------------------------------.---=y.. .:--"---------------------------------------------------•-----.-•---------------
U Nature of Repairs or Alterations—Answer when applicable_:. .:___`--------------------•_--.-•---_.-._-__.__._...._...______
------------------------------------------- -----
>. ----- •------ .x.
Agreement
The undersigned agrees Ito install the aforedescribed Individual Sewage Disposal System in accordance with
,. the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been is ed by the boar alth.
.......................
pDate
Application Approved BY .... = =
Date
Application Disapproved for the following reasons:-------••--•------••---- ..........................................................................
...-•---•-•-•---•-•--......-•--••--•-•-••-•-----•---------------------•------•-----------•- •------------------------------------------------------ --- --•-------•---•-------•----•-•-----------•-
Permit No........................................................ Issued.....�tl' -•• ..... Date
Date
i
s
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF" HEALTH
'L 't o F........ ,;a•'i.- ►._.. ..................................
Trrtifiratr of, f Ompliano
~ T S TO Tliat the Individual`Sewage Disposal System constructed (�') or Repaired )- e-
.b = ------------=-=-----
y aI staller - -- ----Vhas been Installed in accordance with the provi�fons of Ar ' 1 of The State Sanitary Code es ibed in
application for Disposal Works Construction Permit No.- 0`- "�_-______-_-••-_-_-- dated...._I_�."...���i�
THE ISSUANCE OF TH-1,S`�CERTIFICATE SHALL. NOT BE CONST UED AS A G RANTEE THAT THE,
SYSTEM WILI CYIINC.TIOW��i'ATLSFACTORY-.
DATE. C 'i...... ...................... Inspector ...-•--- 7-ft
,
a THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTdF
i
y.....� V!'f ......OF.......
.:.:, .................. /
No. .................. FEE./�..............
friar ' atrrtit
Permission pis reby granted-.. `'-----------•------ ----- --=... ..............................................
......
to Constr or.Rep ( j� ndivldu a Se ag , po em / <
at No.. ►- .-- 6( =�~/--�- = .. . =........... •----
V eet
as shown on the application for Disposal Works Construction r i.t N ate. ._ ¢•Dd
Board of Health ;
DATE.._ . " _._ °
• ---------------------------- ---
s -
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
. , . . 4+
100