HomeMy WebLinkAbout0023 COACH LIGHT ROAD - Health (2) a � Cage 1 r h� �o�
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No. _`...�..._.. Fes$....r��o .A..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
74 �_...............'OF......�,`i%,%lk4,rooY6G ' ......-.......... ..............._..
SIR 1�1-lo'� Appliratiun for Dispusal urk�orRepair
unotru#iun atni$
Application is hereby made for a Permit to Construct ( ( ) an Individual Sewage Disposal
System at:
.....
Location_Address _� or Lot No.
�3 .......,.. :ti(E ..:....C?.:.. & ...... .......:........ ...................
aG L Owner ., Address............ ..................fr-.'d:�.JC..................................... ..._........................................._.............._._........_._.............._.........
Installer Address .
UType of Building Size Lot..n/&_.v!V....Sq. feet
Dwelling—No. of Bedrooms........ .............................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building . No. of ersons____________________________ ShowersCafeteria
a g •------•----------------••- P ( ) — -(-----)-
Other fixtures ------•--------------------•---...-•-----•------------------•-----------------------------------------------------.
W Design Flow_.____ �70............................gallons per person per day. Total daily flow.................._.........................gallons.
WSeptic Tank—Liquid capacity,&6 gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No.____._ ........ Wid�h___ --------- Total Length.................... Total leaching area....................sq. ft.
iamef .. Depth below inlet.................... Total leaching area..................sq. ft.
Seepage Pit No._10 Qd. D
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_______________________.
�14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 --•---------•----•----------•----------------------------•--.......-•----=•---------------•-•-------........................ ................................
0 Description of Soil----•--••---•-. �ek.el --------------------------------------------------------------------------------------------------------•-•---------------_.._.
x ...........---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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 aI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the bQard of health.
�(� �� 2�
Signed.__�_.__^-_�...` .._.._ . . ._C!"�.�s.��'�`. ��� .�................
Date
Application Approved BY = � /' ---------
Date
Application Disapproved for ' e following r o. ns---------------------------------------------------------------------------------•-----------------.._._...------
...=•-----------------------------------•--------•---------•--...------•-•---------....---••---------------•- ---------...---------•---•---------------------------•-----------------------------------
Date
PermitNo-------................................................. Issued........................................................
Date
Yv __
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..................OF........
firafivn for -4posaf Works ontrurtion Punfit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
4 yy
Location.Address r'r or Lot No.
............ .. .... ...... ..£,.; sr...1.. {;... ......... ... ................................... ..............................................
Owner _„ I �Address
j ................. ..s ...s ......... ...afi ..y..................................... .............................................. r...............................................
FMi ..Installer .Address
d Type of Building Size Lot...,..,'!..,_eAo.0...Sq. feet
Dwelling— No. of Bedrooms........`.............................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building -------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures
d ...•••• •• ....._...-•••--••••--••------------------•••----•--•--•••-••••--•••-•••-••••••-••••••...........---------••---------
W Design glow....... ..............gallons.per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid .capacity. /2 ggallons Length................ Width---------------- Diameter......---------- Depth................
Disposal Trench--No Width ..... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No. �+?[ 1.x !6iametef... ..... .1` :..• 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-___.__-__-___--_----_.
lz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
. .................-.............................................................................................. ..............................................
O Description of Soil..
.............
`°x ---- ------•------•-•••••••_.. . .
•:....,
-, .
W ------•---'. -•-••--•••••---------------•••••--•••-••-•-•------•----•--••-•--••---•••.......
------------------------------------------------------------- --------------------------------------------
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 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 issued by the board of health.
R a
Signed. . .� -A .......
3. p.. Date
Application Approved By........ ............... -•.•..•.•--•;
. ,, I sY------------------------
- � -•-•-- •• ----•-•----....._-•- r-------•----
Date
Application Disapproved for t following realsons-------------------------------••-----._..._..........--•------••---•--••---•-•--•-•-•-•••••••. ••••......._.
.................••-----•--•-=-•-•-•••---•--•-------•---•.••••-•••--••---...--•-•••••••••--- --------•-- --------------------------------------•-•----------•-•-•--. --................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-, r, .; ...........OF...........
7.r� ,s. .
Trrtifirat of I utpfi�tnr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ' or Repaired ( )
-' lustaller .
at---------------- ;"- 6"" .=='�w / *�- --- '%" ......................................
has been installed in accor ance with the proslsiq s 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 RE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........ -A. n-3---•------------•-•--------- --------------- Inspector.--- :. .`...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF.. ........ e r
........................T �{. .1
.� '..,ray..✓ ..........................
No...................... �=�. FEE........................
v Wspmal Warkii Cpnnitrnrtivit thrutit
Permission is hereby. granted - := ¢= .......................................................
rr �� o.0
to Construct:()'.) or 'Repair (' )'an individual Sewage Disposal System
c= i
at No.......� = =, ... . , =.>C1 r ........................................
Street
as shown on the application for Disposal Works Construction Permit No:....::...... .... Dated------- / ..................
. --••----••---•••-•••••••••••••---•--•----------------------------------•-••-••......-••-••....._•••_..._
Board of Flcalth
DATE.....................................................-..........................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
A.
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