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Home My WebLink About0152 CLIFTON LANE - Health (2) Q q-7 0 [S I - No..... ' F�$..;..1.........••••....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA1 TH ---�/lL� L................. OF.... . a.. ........ .....'..... ................... ..... Appliratiou for Dispaual Works ( oustrartiou ramit d� Application is hereby made for a P mit to Const uct ( ) or Repair ( ) an Individual Sewage Disposal System L . -- Loc on Address / ATo. • . Owned ..tiX-...,tddre� .:r....... a .............. iQde4'•4 ..... i� ...,..,.•sF,jr.. .. .,.. .., .................. ..... . Installer Address Type of Buildin Size Lot.7..' . .......Sq. feet Dwelling No. of Bedrooms..............�....................Expansion Attic ( ) Garbage Grinder ( ) P4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures -------- --- --- -- - /,�.�- - W Design,Flow.................. .............. gallons per person per day. Total daily flow----------- V-.4. ..�...........gallons. WSeptic Tank Liquid capacity�:�_gallons Length................ Width..______-___---- Diameter--------------.. Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. x . Seepage Pit No--_-_--___-_-_-_-_- Diameter.................... Depth below inlet..........._........ Total leaching area.r3 �-.sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-_--_---___-_-_-__-.-.-. (� Test Pit No. 2................minutes per inch Depth of TestrPit.................... Depth to ground water................... 0 Description of Soil.................. x U -----•-----•--------•---•--------------••-••---.._...•-•-•-••...-••......•-••••----------------•----•--•-•---••---•-----•-•••-------•-•---------•---•----••--••-----------------••--•.._..............._ 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 ' sued by the board ��off��health. Sigd.. ......... ...... . ........... ....................._.......... Date Application Approved B L DaEe Application Disapproved for the following reasons: .......... .................•-...-----•-•-•....-•---.....--------------••---------....--••--•-•...---•--•---•-..._....------------••-..----••-••---•-••--..... --...----- .................................------. Date Permit No......................................................... Issued..... •Z------7 _----- :- .••.. te. No Af...... Ficic .................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® -OF HEALTH t-]] . y.,ems -------- - -------Qr- . far i-q •isal Modg. Tonotrurrtion Vamit Application is hereby made for a.Permit to Construct ( ) or Repair (_ ,) an Individual Sewage Disposal System a ;�� ...w .., - J' �.•"-��t � ;. "„� '.............................................. ......................... . LZOn, •Address .... o Lost No. ,�.�pta•vgK�44 �� +1 ....... ' Owner � Address i 'a Insta err'"" ... ., � ......... � .a. ................... Address Q Type of Building Size Lot... _ ~.? _.......Sq. feet aDwelling: I�'o: of Bedrooms................ ....................Expansion Attic (: ) arUage Grinder :( ) aOther—Type of Building ----------- ---------7...._.No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures . W Design Flow....................�� 4 ..............gallons per person per day. Total daily flow __-__-- > " _____-_.--gallons. WSeptic Tank-L Liquid capacity etlgallons. Length................ Width___-__........_. Diameter...._... . 15epth................ x Disposal Trench—No...................... Width.................... Total Length...................... Total leaching area....._..............sq. ft. Seepage Pit No _---_-- Diameter.. ....::..:.... 'Depth below inlet..................._ Total leachirig.area:.,0.,0. :,.sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.............................................................. ............ Date........................................ Test Pit No. 1................minutes per inch :Depth. of Test Pit---.---__---..____-- Depth to ground water-_---____---_-_-_-----_ rZq Test Pit No. 2................minutes per--•rich Depth of Test Pit.................... Depth to ground Water--__.___-___.___---_-_-. --• •• --......................................................... O Description of Soil.:.. - . '- f- ------------------------------------------------------------------ U .............-............................................................................................................................. 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 ssued by`the'board of health. Sign d,. ...............�. r - Y Date Application Approved Bye _Da Application Disapproved for the following reasons:. ------------ - - ........................................................................................................................................................... ............................................. Date Permit No......................... .--•... ....... ...:::. Issued--•• ------ ., ate -..,..;�•r. �G.-..,. -._r j...t w.::� .•' ..`:si;'a�.�^.:'�y. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTIH r ._................. G1F.......}E ^"r �' e. ...................... 11� Y, That th Ind, ' ;ual � e Disposal e constr ted ( �°�or Repaired ( ) r ,y ? � THIS IS T CER IF � � - �i --- ............................................ Cr r -----6........Jk-•fi-_"r8...................• has been. installed an accordance witl the,provi,.iions of Article XI of The `t ate Sanitary Code as described in the application for Disposal Worlds Con.st uction.Permit No------------------- ----- dated- . THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL F CTIO SATISFACTORY A. DATE...... Inspector .... �. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF..HEALTH NO ... ( u��-^c OF4a� e'>:a�? J............. FEE. ° ..... ..... . FEE.. .... 4 -f Permission,is hereby ranted........ , � . ............ - g k: Put tin a it to Constructor Repair ( ) an lrydivr ual Sewage,,,Disposal System at No '��' a ' .� .3 `., ..- t +dam Street as shown on the.application for Disposal•�l�orks Construction Permit No. � Dated 6 r ,. h ................- _ � d -j � Foap of Ffea�tl�x' DATE------ __ FORM 1255 Hoe BS REN. INC., PUBLISHERS „