HomeMy WebLinkAbout0070 GREEN DUNES DRIVE - Health (2) �0 ✓&,,A V,1`l erg i .
No.-- - -......... ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALT"
fi ��lle Appliration for 1hop al Works Ton rurtivu rnmit
Application is hereby made for a Permit to Construct (Repair ( an Individual Sewage Disposal
syst t: � 4C, 6.
� oca' .dress / or Lo o.=��'4'A%
wn r Address
:Z
a . --..---•-.•-- . ......... .........................................
d..
Installer Address
Type of Buildi)5.1 Size Lot............................Sq. feet
Dwelling'' No. of Bedrooms...... ..... Expansion Attic ( ) Garbage Grinder ( )
p,, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures . .._._
W Design Flqw_ _ ......._...� .___.. Ions per person per day. Total daily flow....... ...............................•gallons.
W Septic Tank iquid capacit � g P
.----- allons Len th________________ Width_...........___. Diameter Depth
x Disposal Trench T,o--------------------- Width--- 1 ching area-- sq. ft.
Seepage Pit No.._. _---.__------- Diameter _ __ ept 1 e�fth._.,�tal
✓ a leaching rea..... ........sq. ft.
Other Distribution box ( ) Dosing tank ( ) ea��
a Percolation Test Results Performed by................................ _._.. .................... Da e........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(� Test Pit No. 2................minutes per inch Depth 0
Test Pit.................... Depth to ground water........................
Q+' ---•---•--•-----------------•-------•-•--•----- -•-•-- . ' ..................................
O Description of S ��--`�= -- - ---- ---- - ------- -- - - ----•------------------
U -----
w —
--------------------••--- - ------------ ....%---••••�----------. i-, e
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 'he u. iersi ne r r agrees not to place the system in
operation until a Certificate of Compliance has ,een i d o of i.
igned - ... .. g.. .. ... .............. .................... .............. -...............
7ate
Application Approved By-- - -------------- - .
Application Disapproved for the following reasons:----•---------------------------•-----------•------------------•--------•---•-•--------•--••-•------•------•----
----•-•--•--....-•-----------------•-----•--•---------------------------..._.............--•-----------•---•----•-------•'---•-•----•••----••----•-.-------•-------•--•----•------------•-----•--•......
Date
PermitNo.......:................................................. Issued........................................................
Date
A_.
No.....V/......... 1 F��.. ... ..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OE HEALTH
w
Appli.ration for Dilipm l lVarkii Cnonstru.rti.ou rermit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
_ Syst t //•ryry /y�
.........?:'5i:. _ ...:.
o �y .�...........
�
--- .....
y
.... + ra n dress or
.... .....r.................. F . Lo
.�� . .......
.... �
wn r Address
... ............. ..._._ .. .�...... ..... •............••................... ...•---
Installer
I Address
Type of Buildi :' ^'''"� = Size Lot................. .......Sq. feet
aDwelling—No. of Bedrooms___i�„.r�' .....................Expansion Attic ( ) Garbage Grinder
aOther Type of Building ............................ No. of persons............................ Showers ( )'— Cafeteria ( )
Otherfixtures --------------------------•--------------•----------------------------
. ......
.......
W Desj Fl w_. :_..:___________________ Ions er erson er da Total dail flow_...._* P P P Y Y gallons.
WSeptic Tank Liquid capacrt allons Length________________ Width_____.___._____ Diameter ¢'___...___ Depth............._..
x Disposal Trench o ____________________ Wult i__ 1 th tal Ching area__ s ft.
Seepage Pit No ' Diameter• _. e tKileow`i iI et `" " "
P = o a leac g rea-- o....--__s . ft.
Z Other Distribution box ( ) Dosing tank
wJ
r"
I--I
a Percolation Test Results Performed bY--------------- ------ -------- -------•-------= ---•-=-_...._ IDa e-----
Test Pit No. 1................mmutes per inch Depth of Test Pit.::....__...........q_ Depth to"'ground water..._....................
44 Test Pit No. 2..............:.minutes per inch Depth Test Pit.................... Depth to ground water........................
P4 ....................................
Description of Soil.................. . .. -- r.
1' .-----•-----------
----- +�-----• .. ----•-.......----
U
x Nature of Re - - --------•-------------------------------------- •-----••--•--•--•-----
U p;,.
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 they?State Sanitary Code he u ersi ner agrees,not to place the system in
operation until a Certificate of Compliance has een is d o o f the
igned > e .
Dat
Application Approved By... ,/ _ ...
ate .1
Application Disapproved for the following reasons:- ---•-------------.........----•----------------------------•- ........................
.................•-........------------•--------•------•-----------•-----------•---......------..:-_......•-------------•----•-----•------•-------------------:----•-•-----. --•--------------•--•-
Date
PermitNo.....:.........' ••-------------................. Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS r,.
BOARD OF EALTH
1-11-
THIJ IS T ' ERTIF ', That the Individual Sewage Disposal System constructed ( �orepaired ( )
by •- ............................. -•-----------------------=--••-----______--- -------- __-_____ .------------------.......
' Installer
atoff, + ` =�"=- = •--••-----•----•--------
has been installed in accordance with the provisions of Article XI of The State anitar Coe a tle'scribSA in the
application for Disposal Works Construction Permit No........... : +/............ dated.----
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. _
DATE ......................................................... In' ector....................•••---•--•----•-•-•-----................_..:._::....... :.....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAL
OF �;`,
No
-• f••• 7!\ FEE
otapaga r vag ion frruti
Permissio is reby. ranted.-* . -- .. ._ ..... �: n
to Construct (` or R it ( ) al;, Individual Sewage Disposal,System tif, N s
at No........ ... .., .................................. 3:.. rj
.. ,1
Street
as shown on the application fo Disposal Works Construction P"" No.__..___
.._ ..
-l y Board of Health
/ _ '-• --- ••.,.•ems:.
...........
.DATE-----•- --- -•-- .....................
• '
"FORM 1255� .HOBBS & WARREN�INC.. PUBLISHERS
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