HomeMy WebLinkAbout0023 HOLLY LANE - Health (2) a3 ��I� �,ne, (�.
No.__�.91...-----= r Fink t2....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
OF.... v --- ------------------------------------------
App i.ratinn -for Utspoiitt1 Morkii Tomitrurtion Vrrufit
Application is hereby made for a Permit to Construct ( ) or Repair ( Individual Sewage Disposal
Syst t- _0, , - e , t
__-_
'------- -
------
cation- ddr., or Lot No.
------- ------ ----------- iv,
Ow r Address
P
r, > � --•• --- ---•---
nstaller Address
QType of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms-----------------------------------_--------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
0.i Other fixtures ----------------------------------
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth___----__--_--
xDisposal 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 Test Pit-------------------- Depth to ground water....................
._-.
fi Test Pit No. 2................minutes per inch Depth of Test Pit-----------------___ Depth to ground water------------------------
----------------------- ---------------•----------•---------•-----•---------------=----••---__--------------------------------------------------------------
0 Description of Soil.................................................................................... --------___------------------------------------------------------- ---------------
x
�., --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
W _____ _____ ____ _ ______________________________________________________________________________________ ___-_-__--__s_ _- _____°'__..._-_____ ____-__ -_
•• ___�_ '^�' ""�___• - __ _ - - - -----" ------------------------
U Nature o Pe irs or A terati s er hen ppli bl C,>�_-___......... .------- -- - --- --
4---------- �
Agre ment:
The undersigned agrees to install the aforedescribed Individual age 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 n sued b th oar d f h.
Sign - ' ------------ •-�`'
u Date
Application Approved By------ -------------------- -•-- ". ..�... .._..-
Date
Application Disapproved for the following reasons--------------------- -------------------------------------------------------------------------------------
-------------------•--------•----•-•-----••---------------------------------------•----•---•-•- --------------------• •••-------•-----•-------•-•--..._..----._.._._......._...--------•--•--
ate
Permit No......................................................... Issued.----•-•-T ---_S 7J
-- -------------------------
-
Date
S
No. -1•- 4---........ Fs$... ...... .........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
-...O F.... ..... ------ -------------------------------------------
Appliration for Dispniittl Works Tonstrurtion Vrrm t
Application is hereby made for a Permit to Construct ( ) or Repair ( an IndiviC ual Sewage Disposal
Systemrat• /
- - .......... ------- -- ----- .......................................................
L cation- ddre'ss/ or Lot No.
----------------------•------------------ . --
7 OWAddress
-------------------------------•----------
L` nstaller f 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 ( )
'-, Percolation Test Results Performed by.......................................................................... Date........................................
a
Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........--.---.--._-_-
f� Test Pit No. 2___•-_______.___minutes per inch Depth of Test Pit.................... Depth to ground water-.._.---______--_--. --
----------------------------------------------------........................................................................................................
ODescription of Soil........................................................................................................................................................................
x
U -------------------------------- ------••------•-•-•---•-•-•------•-------•----•--------•--•-•-•-----•-•-••--•-••-•---••----•----••---••----••--•---------•--•--••--•-------•---•............--•---
W ------------- ------------------------------------------------------------------------------------- ----
U Nature o Re atrs or A terati9ns wer hen ppli bl _. _ � ___ _ ... �- .C.,�.--_----
� '� _ice_(_ s% ............... _"A--:`.-- - - -- ------- --
1
Agreement:
The undersigned agrees to install the aforedescribed Individual wage 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 eaten issued by t board f h. �,,...-
Si n !"J ���_ i1� '
g - - ;?�•-----�'-.- �
Date
Application Approved By------- -- --- - ..................... ......
_a_..'.... .,5..
/ 7----•---------------------- --••-------•--
Date
Application Disapproved for the following reasons________________________
----------------------------------------------------------------------------•-•-•-•-•-----•---•--•--•-•••----••-•--••--•--•------•--•-•------------•-----•••-••••----•-----------•-••--••-•----•--------
Date
Permit No.-------................................................ Issued.-- -- ......................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD .F HEALTH
. .................................OF...... .. .... ..G t .........................................
i
rrtifiratr of Tompliaurr �
THI S TT CE FY is e Individu ewage sposal System constructed ( ) or Repaired ( )
by--�`... �� �-------- --- ------ --
Installe � p,f�i
at.......... . .--.. ...�------ ------------ '? 7 , �-: 0( A..-.
...............................
has been installed in accordance with th provisions of A �; /� The State Sanitary Code as described in the
application for Disposal Works Construction Permit No(--- ---------7'_1----...__._... dated------ .........
THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUE® AS A,GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. �%���
DATE.............. �-� ---- Inspector--------------------------------- --•--• ........................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF EALTH
o-d
� �.it���.......O F................ ..... ....c _....------------...........
No...L�'�_,1..._..__.. FEE- -- ................
R_Xly o fia orke010 rttrfivit rmit
Per fission is hereby granted________ ___ ____ ..., ............ . ... .. ..../I.... .
to Con t uct ( ) or pair ( Individual�Sewag po yst
atNo. . -- �----°� .. ........ . ......-!-��....-----------.....---r-----------------------------•-------
st
as s wn on the application for Disp sal Works Construction P i No Dated.... _- _-_7__�.....
'-----.•.--•- ��' ..1 1 .rC.
--------- -----
DATE.......... ------------------------•----------• Board of Health
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FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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