HomeMy WebLinkAbout0045 DUNASKIN ROAD - Health (2) L/s �wnc�s�,� �. , Ce,.�
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No......................... 11 a 0'`7 Fa$.. —��
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_. ._..........OF_
..... . ... .- -.....
ApplirFatiun -fur 130puual Workii Cnunutrurtiun Vrrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Locatio -Address or Lot No.
Owner Address
c:l
a •--------- - •r•--- -- .. •-- Installer Address
--•--...__.._..----•--------...._...._...-•-Address---......_.__.__..----•---•----••----------
- star ............................S feet
U Type of Building Size Lot q.
Dwelling—No. of Bedrooms-------------------------------------------_Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No, of persons............................ Showers ( ) — Cafeteria ( )
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 ( )
Percolation Test Results Performed by-------------------------------------------------------------------------- Date--------_-•••----•------------------
a Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water.-.-__-________-_---_-_-
rXq Test Pit No. 2---_------------minutes per inch Depth of Test Pit.................... Depth to ground water-_-____________-______--
-----------------------------------------------------------------------••-•----••-------•-••••-•--•-•--••----••••-•-----••-----. ............................
Descriptionof Soil----------- ---------------------------------------------------=---•--------------------------------...----------------------------------------------------------------
x
---------------------------------- ----------------------------------------------------
- J I------------------------------------
U Nature of Repairs or Alterations—Answer when applicable.-.---._._�L�`___-_ __.___ ; � ` '
-- -------•----------------------------------
m
6,
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.
Signed
®
Application Approved By--_--------------------4/� ,- l D ate;?j—
Date
Application Disapproved for the following reasons_________________________________________________________________________________________________________________
--------••••-•...........................•-------------------••-•--------•-•-•---•-•-•-••-•-••------_•-••..•---...•-••------•----•-••...-••------------------_--••--------------._....------------•-••-•-
Date
PermitNo......................................................... Issued....................... ................................
Date
17
No......................... ..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...... _ T.. _...............OF............ w>t<(_ . .......;- ..............................
Appliration -for M,4,poott1 Workii Tonitrttrtion Perutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
................................................................ .......................
j rf Location IAddress�. or Lot No.
' ) 'Yt-G�' ..... _ ..................... .................... ............................................
Owner..04._4.1 ::..
............................................Address
W /. -
Installer Address
UType of Building Size Lot............................Sq. feet
�-, Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons.--------------------------- Showers ( ) — Cafeteria ( )
Otherfixtures ------ -------------------------------------------•----------•-----------
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........................
ri-4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
9 ----------------------- ---------------------------------------------------------------------------......................----------------------------------
GDescription of Soil---------------------------------------------------------------------------------------------------------------------------------------------- ------ ..................
x
UW ---------------------------------------------------------------------------------------------------------------------------- � ---------------------------------------•----•---•-------------
Nature of Repairs or Alterations—Answer when applicable.=...._�'<�j�� �___._.2 ` � :v_. ......� -�
2 c-r-�-
t --------------------------------------------------•----- -----
Agreement:
The undersigned agrees to install 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 issued by the board of health.
Signed--------------------------------------------------------------------------------------- ................................
lam/. Date
Application Approved BY f - --------�-!��__l-------------------------------------- .... --'....% _"...
Date
Application Disapproved for the following reasons---------------•---•-------------••-----•--------•-•-•-••-----•------------------------------•--------------•----
......•--•-•-----•---•.............•.---_.._..--------------.•---•-•--------- -----••-------------------------------------------.------------------------------•----------------------•-----.-----------
Date
PermitNo--------------------------------------------------------- Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF H.-ALTH
...�!� ....... ..OF................. ....;..............................................................
Tertifirute of ffoutpHattre
THIS IS Tr
LERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by 1J ; � tti/
..... OF...;F .. ..........................
- ---
f1�..•%---------------------•--------••-----..........................o Installer
has been installed in accordance with the provisions of ArticlELXI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.-�_y....�. /�__S. .......... dated_-.'?— -'7_.'_.1 1`�...............
THE ISSUANCE OF THIS ,CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..........................................•••---•---•-•----•------•-----------.. Inspector--•----------------•----------------------------------•------------------•-----•----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
J
17
�� `--"
No.-j-------•--------- E-----'---------•---------
DinvagT,x.I.J
or, n trttrtio$t rrutit
Permission is hereby granted......_. Y ` / ..0 ----------------------------------------------------------------•------•--•-------------
to Construct ( ) or air 7) an Infividual Sewage Disposal System -
. J
r.at No.. ... �l r -k � 'i 1 t i f" y--------
Street-
as shown on the application or Disposal ors Construction er"' It -/-�---�fD�ate�!d�-�--,=--1 ......
�•-.r ..............
--
,
.............•---.........-
DATE....... (y o ard of Health/
-------------------------------------------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS