HomeMy WebLinkAbout0026 COACH LIGHT ROAD - Health (2) Can-ler
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
lv141.4' /.._....-.....OF............�!
t�g Appliratian for Riivasal Wore Cnnni#.rur#ion Vantit
Application is hereby made for a Permit to Construct ( /, Or Repair ( ) an Individual Sewage Disposal
System at:
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o►5G �o T C���''E v� ... ..............
Zb Location-Address �. .�� or Lot No
.... ..... ......................... ............................
..... ........................
Address
Installer .Address
Q Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
'4 Other—T e of Building No. of persons____________________________ Showers — Cafeteria
p' Other fixtures .......................................................
Q
W Design Flow.............S6....0_..................gallons per person per day. Total daily flow........3 0_6___...____...._____._____gallons.
W Septic Tank—Liquid capacity__/l10 Jallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No._____________S.__ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No._/_eA f-- ''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------------------------
(Xq Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
..........................................
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Descriptionof Soil.............-f/9_ _..._.��A� ---•--•--...------------......----------------...._..-----------------------------------------•----------
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 Article XI of the State Sanitary Code—The undersigned further agrees no to place the system in
operation until a Certificate of Compliance has been i by thboard of h h.
Signed. •;�7
-•• it..----•-•�4 G � - -._..._ /l��_7_.�. Date
Application Approved BY- &-- -___- ... --------------------------------------
DateApplication Disapproved for ie following r sons_ ___________________________________________________
--.......-•--••-------------•----•--•--••-•---•----•------••-•-•---•-••--••-•-•--••••--•---•---•--•--••-•-•----•--•-••--•---•---••-••--••-•-------------•---•-••--••••---••-•-•-••--•..................
Date
PermitNo.......... S._..__........................ Issued.............................._.........................
Date
No..... . .... F�s.. _
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7 it r . f,�,, _ *.z,*•
iZ 0�......... .
Appl r tion for lka oiial lgorkii
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at:
r
....... ........: ,i+'_ ........ ...:.t'r A`es4 ........sr r ........._ ............- ¢�„ .: rJ-'-'.
Location_Address yr'- or Lot No
,...,. �.... e `,'. ...... ,...��6..�' ;f`�1......................... .7 ' .. . .?f..��. ✓.-...._!`....� ".?.� .,....
.; Owtler f✓ Address
............... .....:..... ......... ..,: ............................... ........................................ ....................................---•--.
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—.No. of Bedrooms....... ""............................Expansion Attic ( ) Garbage Grinder ( )
` Other—Type M p4-, yp of Building ____ _____._._ No. of persons..".,:: Showers ( ) — Cafeteria
a' Other'fixtures ............................................ )
d
W Design Flow_,__......... ..................gallons per person per day. Total daily flow........ _--__:_--:...............gallons.
WSeptic Tank—Liquid capacity...A•_;_'gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. ................ .. Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.___` -s.<.-:_X41)iatmeter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box(,( ) Dosing tank ( )
W
Percolation Test Results Performed by.......................................................................... Date..........................................
Test Pit No. 1----------------minutes per inch Depth .of Test Pit-................... Depth to ground water........................
f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a'
O Description of Soil_......... �; r':...._ ` -
x ...............................................
V :--••-------------------•--------••-•-•••--------•---..•-•--•--------••••-•------•-••••-•••-•........---------
W
UNature 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 no to place the system in
operation until a Certificate of Compliance has been issueq by th board of health.
lue z,
Date
l ftf '
Application Approved By......... -------- • ------.. _.. - ---- -- --------------- ----•----
.._i
:.: Date
Application Disapproved f or jhe following recdsons:1-------................
...............................................................•-------------------
-
-•-•----•-•----••••-••-•--••...•-••--•--•----------------•---------------••-•--•----••-•---•--•----..._.....-•-.......------------....._...... ..........................................................
Date
Permit No......... Issued ...
Date
THE COMMONWEALTH OF MASSAC,HUSETTS
/7f,/;�t �
'r ,
BOARD OF HEALTH
: . ................OF......E.. ray ,_? . :.....................................
hex x �r tr of Well e
THIS IS TO CERTIFY, That the Individual Sewage .Disposal System constructed ( or Repaired ( )
Insfallcr
at........ .-_._c_._5___._."_____c__• ____.__� ______-_ ..,. ___ -_. __...... ............................. r__ �3_.__.__._.____,_._ ^_
has been installed in accordance with the provisions of. Article XI of The State Sanitary Code, as scribed in the
application for Disposal Works Construction Permit N - dated._.____._/:�-`, :_:_.��____....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED.AS A GUARANTEE THAT THE
SYSTE- WI L FUNCTION SATISFACTORY.
r
DATE Inspector ... ..
.. � r �°
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
l ......................... J
Permission is hereby granted - ti{ = � '` ,f ......••.... ...... . .......
to Construct ( or Repair',.( ), an individual Sewage ,Disposal System
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as shown on the application for Dis osal � street
� � � oils Cony
Disposal f Construction'.P'e i-.'Y o;. .....• Q d----• -- .............................
j , :
DATE----- •.
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS