HomeMy WebLinkAbout2130 FALMOUTH ROAD/RTE 28 - Health IJ30 Wmukl� RA. , (snl .
A It�9 aig
No..�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD !—{E L
�� . -.....OF.......... . . ..... ....::. . ..............................
ApplirFa#ion for Uhipag al Works Tanstrurtintt Prrutit
Application•is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
1 _ �9. r!� .--.. .... -.- - --------------------------------------------------------------------------------------------------
Locat [ad ress �'.fe or Lot No.
O ner Address
---1 ----z.. .......
Installer Address
QType of Buildin_g� Size Lot............................Sq. feet
Dwelling X No. of Bedrooms............�.......�T 3.--.Expansion Attic ( ) Garbage Grinder ( )
Other—Type.of Building .............. No. of ersons..................--.------. Showers — Cafeteria
a yP g -------------- P ( ) ( )
Q' Other fixtures .----•••._.........-•--•------ ..
W Design Flow............................................gallons per person per day. Total daily flow-----.......................................gallons.
1:4 Septic Tank—Liquid capacity.............gallons Length................ Width................ Diameter..............-- Depth................
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.........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-..--.-.---.------------
(Z Test Pit No. 2................minutes per-inch Depth of Test Pit.................... Depth to ground water.....--.................
ww�
------------•----......-----------------------------.
Description of Soil-------- ���
x
w ------ �............................................................
UNature of Repairs or Alterations—Answer when applicably.....L f ill ....dA -e"']`'�1 --=--..........
.............................................T.(
Agreement: I v
The undersigned agrees to install the atoredescribed Individual Sewage Disposal System in accordance with
provisions of i i: � ,t
the p f'1TL'E 5 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 t bo d of health.
Ole
E,
Signe �fs � - �a �
Date
ApplicationApproved By•••-•-- ••••-••••-••.. ....... ..... --- .......................... ........................ Y--
Date
Application Disapproved for the f ollowi r asons:--••-•-••••-•--•••••----••-•-•••-•-•--•-••--•----...............................................................
---------------•----••-----------•--•-------------•------------------•---....------..........------------••-•-•••-••••...-•-••••.......--•----••••--•--------••••••-•••••-•••••• ................
Date
PermitNo......................................................... Issued-.......................................................
Date
01
THE COMMONWEALTH OF MASSACHUSETTS
" BOARD ?F HE/ L TV
.......... . ......OF.... ` � :. ±�'.!.' w _ .. -................................
Appliration.for Dislins al Works Tunti rnrtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( -ran Individual Sewage Disposal
System at ,
,j
LocatipD Address r. or Lot No.
---------------------
.-... - ....
Omer Address
W fir
,� "' �• ' .� ---------------------•--------------
Installer Address
Type of Buildinn Size Lot............................Sq. feet
Dwelling-No. of Bedrooms............ ...._..._i�`!�:u,:-.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—NTo. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by..................... Date........................................
Pit No. I................minutes'per>nch Depth'of Test Pit.................... Depth to ground water.----.--___-_-__-____.-.
f.4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
• `------•-••-•---------------------•-....._._.................................................................
O Description of Soil......._ .� "'e��.................
-•--•••-•-•-•-----•••-••-••••----••-•••---•-----•----•---•••-••----------•••--•-•--•---......--•••••................•-------••-•.....--------•---•-•-•••....•---••-•--...-•--------•---••--......----••-
W --------------------------------------------------------------------------------------------- ----- --:-- ----- ------- -----------------
U Nature of Repairs or Alterations—Answer when applicable_-._. _--_.........
............................................
' -----• .....................
_ �.
Agreement ( G ^j
The undersigned agrees to install the a oredescribed Individual Sewage Disposal System in accordance with
the provisions of i T"jE 5 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 t boaFd of health.
l P /
Signed--•--�-- - == -,1.--., E:r--•---•- ---�°- `="�.�'=-�•
/ Date
Application Approved BY L✓ ......................... /Z >I 1---
' Date ,
Application Disapproved for the followi r asons:......................................................................................------- ------------------
...•-----------------•----...-----•-•----•--------------------------------••---------......------.........--•---------------------•-•---------------------------------------------------------------•--•-
Date
PermitNo......................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
a
BOARD OF HEALTH,,,
.i... ......... .OF.......
.ty ' ✓�' t ,"��b ' • .,1' ......................
,I �p�#i�B�tt�P�-nf�u�t�rl �anr�e
y TIHis S3,T CERTL Y, That the Individual Sewage Disposal System constructed ( ) or Repaired
- --------
,.-• t ./ s � Installer �i d�,- � ..................................................
.
has been installed in accordance with the provisions of 7`1-ZIE" 5 of T State Sanitary Code as described in the
application for Disposal Works Construction Permit No.... �_`!___'.__ .._....... 1
•-- dated-------.. ..--•-•-----•-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
MIA
Y DATE................. ----------------------•••---•-... Inspector...._..
THE COMMONWEALTH OF MASSACHUSETTS
-----� BOARD OF HEALTH
T .......r'Y C .1' t✓f .OF...... ...�..'r` �.{ �.•.W`.................... FEE
o° ��✓'✓���,�
,J .. ........ .........
O..:. .................. EE........................
Dispasat` orks-Tvnst nwit ntit
Permission is hereby granted-_fit, ..............
:... ...._ t-',� •`'
....---•--•................
to Congt ) or , pa_
`)and Indrvldualevcrage Disposal Sstem`�
at No.....................................'.."' ------- ......r = ..:.�. .. .. .
Street 41� ! z , + ��j
as shown on the application for Disposal Works Construction Per\m*t�No.-(-`�___..__•-.�l ated_.-_._� '..�{__.._ _ .......
��E; `-._... -•-••---------------•-•---
f , - .
` Z ' Board o2 eaIth
DATE--------- -------•----•--•-...........................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS