HomeMy WebLinkAbout0024 JUSTICE DOUGLAS WAY - Health (2) Jus-h a h"
L
No....... l 191 I . ` OIN Filic ........
THE COMMONWEALTH OF MASSACHUSETTS
l� SOAR® HEALTH
1 _
OF....... C�J�, ,
Apphratio'n -for Diipuiittt Workii C omitrurtton Vrrmft
Application is hereby in e for a Permit to Co uct ( ) or Repair ( ) an Individual Sewage Disposal
System t
.. ��//.. - ---- ------ -• ..... ......r,..........
Lo Address Lot
.. ............•............ ................ •. •... ..........................................................r /j/�� Address
Installer Address t i
d Type of Buildi� Size Lot_. tt. --_-_Sq. feet
U Dwelling No. of Bedrooms.-.._----. --3 -_--Expansion•Attic ( ) Gxfbage Grinder ( )
H ____________________ —
aOther—Type of Building ---------------------------- No. of persons---------------------------- S howers ( ) Cafeteria ( )
a' Other fixtures _/__�
W Design Flow- ------------- C./ s per person per day. Total daily flow----- Ga... -.------gallons.
R; Septic Tank Liquid capacity __.____ al
Length________________ Width_.._............ lliameter___....._-.._.._ Depth-__--.-_....--.
W Disposal Trench—N _ ____________________ V7ill.------.-._. -�_�.� Lengt -_--_ --. tal leaching area..- .-----..sq.Seepage Pit No------- ---------- Diamete epIJ't . . a ..' otal leacliiu area------------------sq, U• ..
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...-----.--.---.--.--. -
f� Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water-..--.-..--.---.-----. -
----------------------------------- ----------------- ----
0 Description of Soil----------------------------� --- -• - -- ------- •---- -•• ---•---- ---------•--..............-•-•----•---------------
x
-------------------------------------------
w
x --- --------- ----------- ---------------------------------------------------------------------------------------------------------------------------- ---------- --------------------------
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................-
--------------------------
Agreement: ,
The undersigned agrees to install the aforedescribed Individual Sewage D)agr
System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned f ths not to place the system in
operation until a Certificate of Compliance has been iss board of e
ned_._ -
Application Approved By--------'ig
•-•'--... �l
Date
2'// .
Application Disapproved for the following reasons:---•---•--------------------------------------•--------'-------------------------------______.ate ------'-_---.
---•----------------------------------------------------------------------•-----'---•--------•---------------------------•--------------•-•-----•----•- ------------ ................................
Date
Date
PermitNo......................................................... Issued............ -----/ -•F- i..............
Da
�_.,. �.. ----------------------
No. % '�- Fine /�.....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
OF
Applirtatinn -for 1 i-4puiittl Works Towitrnrtilon Pumit
Application is hereby maAe.for a Permit to Co . uct ( ) or Repair ( ) an Individual Sewage Disposal
System t:
---..............................................
�.^
Lo Address
Ow r Address
W .............. 4------- . .eke--_--•--••----- --•---------------------
Installer Address pL .+
Type of.-Buildi g Size Lot../,�f_ W,_Sq. feet
U Dwelling KNo. of Bedrooms_________._.. f6
., g Expansion Attic ( ) Ga age Grinder ( )
Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures __._ _
W Design Flow................\„� . per person per day. Total daily fl ow.._..__ __ ..___..gallons.
WSeptic Tank-Liquid capacity_..:______ allons Length................ Width................ Diameter.__-__-...___ Depth.__-____.-....
x Disposal Trench No- -------------------- Width.. e�ie
tal leaching area------------ ----sq. ft.
-____-:-_ Diameter.... ........ . De t e ...
Seepage Pit No .._. potal leachil n area______._......._sa. ir.
z Other Distribution box ( ) Dosing tank ( ) �•,,�
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date---------------------._---------------
,� Test Pit No. 1----:---------._minutes per inch Depth of "lest Pit.................... Depth to ground water..__-_------..-.__.-.-_.
f14 Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to gr and water--.--______-__.----_----
( --------•- --- .............................................
_
D Description of Soil_____________________________ "
x
V ------------------------------------------------------------------------------------------------------------------------------------------------------------------------=-------------------------------
W
U Nature of Repairs or Alterations—Answer-when applicable................................................................................................
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage. Dispos. System in accordance with
the provisions of Article XI of the State Sanitary Code,— The undersigned ier agr snot to place the system in
operation until a Certificate of Compliance has been iss board of e .
gned -• .-. .. ........... ....•-
Application Approved By..-' ..... -- ... . -• ._ = i./YY ..Dace
' - ate,
Application Disapproved for the following reasons:................................------==-----•-----•---------•-----'•------- ............ ......
--------------------------------------------'----------------------.........................................................................................................................................
F
Date
PermitNo.=m..............................•---------=----------- Issued...................... .................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 2;HEALTFI.,__.... :..... .........OF........... ..........
Tntifiratr of Tnnmplittnrr
THI S 0 C RTIFY, at the Individual Sewage Disposal System constructed ( or Repaired ( )
b
----
at .'^ _. � /��
has been I stall accordance the provisions of Article X of The State Sa ary ode s des c 'bed in the
application for Disposal Works Construction Permit No..............'-/jL---------------- dated----- ' �_ __ t
+'
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A G ARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. -
DATE..................................................... ---------------- Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ` HEALTH
f .:.OF......1. ....fir.."...:L ...........:.................................
PC . llp4No. F= ...... FEE%rip>atittl rk nmi rtibilt ermit
Permission is.>ereby granted------------- --- • .. ........ ------...-----...........__........--'=--........ ...
to Construe or Re air ) vidual Se ag `Dispo 1 System
at No..+__ _-__
•
7 — Street
as shown on the application or Disposal Works Construction Per o.A_. .._... Dated.....! ___
..�^
.....i...... ... ....... .. aAW. - _____
Board of ea tI l
DATE. = �--- •-- ------------------•-•'--
FORM 1255-r 0885 & WARREN. INC., PUBLISHERS - R
{
_,� - .�...�.�...__.._..-.... .�.....,..._..,....,.,.._.,...,.r__._.._..._.,.._ __....� ..
�, ,�`
ft� '-'` .
� `
k\� ti.rY' 1 j 1 J�f
� �'
� £
� l..
. fib �.` ,,`� � ` i
��
/� i / 3
,�\.
� �' !+
` �S, `F� ,'`' Yr ,r. � 4
3
!� �,�,
i '},\ P
� \� � 4
�`
.�i
(� � � �4�.
'-... `' �
�. '
"t i
�� �
* �
.�-
.N� �-- �i_...___.�...__._._....�.,��...�..._...._._.._�.a....._. _..�.._. _V..._.______._..
:�
"`� r`
f