HomeMy WebLinkAbout0003 HAYWARD ROAD - Health (2) ��(o�b�4/00 i
No...... Ana.g FBs.....5_�ee......... 3
THE COMMONWEALTH OF MASSACHUSETTS .
BOAR® OF HEALTH SUM'ECT TO APPROVAL 0F
..................... ....................o�........................... CARNSIARLE CONSERVATION
OMM
1 A ltrFation for Utz m al Workii Cn nstrurtinaa prnitJsl®N
SyApplication is hereby made for a Permit to Construct ) or Repai ( ) an Individual Sewage Disposal
stem at: �12.
: .... ..................•------------------------
Location-Address or Lot No.
....................................................... ...... .. •--------•----...........---------•-----------------
Own z Address
W �.. ............... .....lglkr 'EfL£
Installer Address
UType of Building Size Lot............................S q. feet
Dwelling—No. of Bedrooms..-....................................Expansion Attic ( ) Garbage Grinder ( )
pa,, Other—Type of Building ............ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ----------_---_--- ---------- -
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity-VA. .gallons Length................ Width................ Diameter.-.-..------_-. Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area..s SV..._.__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........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......---...........--..
R+' y....................
O Description of Soil------------- ... -•
W
........................................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable-----L'su.7............... ....r .........................................
E,�tni
--------•- -----5-7---f- Lf 1 t!4t -----.k W*.......................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLL 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 the board of health.
�� i
Signed• .........P. ---•--• y
Application Approved By... .... �.....,, . ... .. ��
Date
Application Disapproved for the following reasons:................................................................................................................
..............•-----•-----..........................---------.........--••-----------.............--•--•.••-----------•-••-•--•-•-•------•--•--••---••-----------------•-•------••----------•-•---------
r Date
PermitNo......................................................... Issued-----•-------•------•-----•--••-----------------••••--
Date
y
No.----. .:. r*� Fimic 1wt�.-.. :.......
THE COMMONWEALTH OF MASSACHUSETTSwr
BOARD OF HEALTH
------. -- ..........................OF.........................-----..........
Appliratiun for DWpatial Works Tunitrurtiun Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal
System at:
........ ........R.&..t_41tanc E?: 1 omk.... !!P
► .t .....
Location-Address or Lot No.
Own Address
a C:� . T L
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.....................................Expansion Attic ( ) Garbage Grinder ( )
W Other—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.I'Pa .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.....................-•---------------
Test Pit No. I................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........................
P4 ----------------------------------------------7........................... ••----••-- - •. ti ;
..............................
O Description of Soil.............. ....----U-&,t s ---" to ..... r
x
W
U Nature of Repairs or Alterations—Answer when applicable:_...AV. ().._.� �!!ftt....T kk x...................:....................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T ITLE 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 the board of health.
Slgned.
-------------
Application Approved"B it . ,f
Date ,
Application Disapproved for the following reasons----------------•----•--•---------••--------------------•-----------=------------•-----------------.....---.._.._
--------•----••-----•------•-•--------•----•------••---------------------------•---•---...--------------••------------•--•-----------•-------------------------•----------•---•------------------------
Date
PermitNo......................................................... Issued_.....................................................-
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF.....................................................................................
f�rr#i�irtt#r of f�lant��i�nr�e
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired ( 44" .
------------------------------------------------•-•--•---•-•--•----••••....._
Installer
�...----•--- ----------
N.�k_ti!W ? ` �Q
at.......... ' " �^ ................... ''11.1/11.� ,,�
has been installed in accordance with the provisions of TIT F 5 f T e State Sanitary Code as described in the
application for Disposal Works Construction Permit No---- _:��'_ ...__...... dated-......... .....................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.. ...... {.... ............................ Inspector..........A-4 }
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...............................:O F................................................................................-....
No....A?2:./6' ' S
...__. FEE........................
Dispsat Workii T nutr ion anti#
riC.
Permission is hereby granted---------------------------------•------..................................----...._---------------------.......-----......_.:._.._......_._.. .
to Construct ( ) or'Repair ( %meKn Individual Sewage Disposal System
at No... Z 1' lnL'P1?„ -------- t= 'Lt ...... 'Vlt►L
Street
as shown on the application for.Disposal Works Construction Permit No..................... Dated._,, ----------.-_.-------_----_-________
-'00
•--------------------••------•----•_
BoarH
DATE..... -•----------•-----•----•------•--
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS ,