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HomeMy WebLinkAbout0024 CLIPPER LANE - Health (2) a C4'o p-er LoAe,c c�/L); tic No......................... Flora.,1....................... THE COMMONWEALTH OF MASSACHUSETTS m - ou � BOAR . OF H TH .?.". ............OF. ............... ... ....... ..................................... Appliration -for Dhipoii l Workii Tomitrurtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair VVX) an Individual Sewage Disposal System at --- • .-- WVde --� 11� - �— cation-A or Lot N . L. p , . . -------------------------------- e � y Owner �= AddT y. w •--• -� -•----•--------------------- Installer Address UType of Building Size Lot__________________________Sq. feet -, Dwelling—No. of Bedrooms_----.5..............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) d Other fixtures ------------------------------------------------------ W Design Flow............................................gallons 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 ( ) aPercolation Test Results Performed by---- ---------•---------------------------------------------•-------•----- Date------------------------- --•---••----- ,� Test Pit No. 1................minutes per inch Depth of "Pest Pit.................... Depth to ground water........................ fq Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ -------------------------- •-------------------.................-•---------------••--•••--••••---•••••••-•--------•------------...... ....................... ODescription of Soil........................................................................................................................................................................ x UW ---------------------------------------------------- --- ----------------------------------------------------------------- Nature .f pairs or Alt rat?s�—An wer when applicable....___/ ©.0..._.. -. .5 Agreement: The undersigned agrees to 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 sae y the boar of health. Signe --•- -,----------------- Date Application Approved B Date Application Disapproved for the following reasons:-----•--------------------------••-----•-------•----------------• .............................................. ----------------------••---•--------------•-•------••----•-------------••--•---------------•----•--•--------------•---•------------•-----------------------•--•---- ----•-------------•------------•--- Date PermitNo......................................................... Issued.....................---................................ Date ------------ -----------------------= No..`J.-7.5..... t, Fish._ ...................... THE COMMONWEALTH OF MASSACHUSETTS �----" BOAR O F H � T H %. r �.. .._........0F_� ..............31 ............. ......... .................................... . AVVIirtttinn -for M-4Vviittl Works Towitrnrtion Vrrntit Application is hereby made for a Permit to Construct ( ) or Repair (kran Individual Sewage Disposal System at L cation•Ad .es or Lot No 4_X/ Owner / y /Address— —D---------------•---............------• ......------ C.fr{.--•--•-_W� ............................. Installer Installer Address UType of Building Size Lot............................Sq. feet �-+ Dwelling—No. of Bedrooms.........------------------------------------ Attic ( ) Garbage Grinder ( ) aOther—Type 'of Building ____________________________ No. of persons............................. Showers ( ) — Cafeteria ( ) Q' Other fixtures W Design Flow............................................gallons 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 ( ) aPercolation Test Results Performed by-------------------------------------------------------------------------- Date----.-----------------------•---------- 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-------------------- n' ----•--•---------- ---•-----------------•-------------•--------•-•-------.....•-----•--•••---------.....------.....-•--••-----•-----------•------.-•--- ODescription of Soil------•------------------------------------------------------------------------------------------------------------------- --.-•---•------•----------------------------- x VW ----------•------------------- ----------------------------............---------------------------------------------------------------------=-- ----•---------------------------------------------- Nature o�pairs or Alteratip�r s;Answer when applicable.-------Zef� .� -� - -- -----------=-------------`- 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 ed by the board of health. ,c Signedf�' . - .......-•--- i 1 -s-�- ApplicationApproved BY----------•..............•-----------...--•-•--•----•-••--------•--•----•--....--•--------•---•--- ---------•-----•- Date Date Application Disapproved for the following reasons:-------•----------------•---------------•-----•-••----••-------••--•-•---•--•-•----------------------•---------- --------•--------------------------------------------•-------------------•--- ---•--------••-•-••--•--•.... ------------------ Date PermitNo......................................................... Issued.-------•----------------------------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAALLT�K ................OF.....���/ l✓i7r!7/!!v..t^ ..................................... %Dutifiratr of OTIMplianrr THIS -TAX-E ;FY, That the Individual Sewage Disposal System constructed ( ) or Repaired (4—T— by.......... -- ;iccorance Instahas been installed ind with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A ARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE. F �� � -- Inspector... - THE COMMONWEALTH OF MASSACHUSETTS -- BOARD OF HEA T_ H r 7".1�............OF...... 16i4........ �S � 0 V No -•------- --------• FEE---'................. �i����ttl �rk,� Cn1Qn�tr�tr#inat �rrntit Permission is hereby granted___' � �-t___.__;t `. �'<! ..r to Construct ( ) or Repair (�) an Individual Sewage Disposal System at No..... — �4 .- .... /� •--•--•--�-.__.... � -----�`---------------------------------'----..".Street-----------•-••----••-•----------...--•--------••--••-•------••-•--------...... as shown on the application for Disposal Works Construct* ermit �rs ated__��rr .. --- . --- -•• ----•-- ------- -- --- --- DATE..... ---------------------------------•- Board o FORM I255 HOBBS & WARREN. INC.. PUBLISHERS