HomeMy WebLinkAbout0125 KNOTTY PINE LANE - Health (2) /a5 ��N� �'ne� Ln ., Genf-,
No....1.9 f...... F��....... ..��__..-
...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD PF HEALTH
Appliration -fear Disposal Works Tonstrurtion Vrrnift •
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Application is hereby'made for a Permit to Construct ( ) or Repair (` ) an Individual Sewage Disposal
System at:
-•-Loon- ddress � - Lot
1 k
LIM/
Owner Address ,/
-----••--••••..._..•-----•--••--•--------•---•---•••-•-••--------------------•----••••.
Installer Address
d Type of Building Size Lot............................Sq. feet
V Dwelling No. of Bedrooms________________________ -Ex Expansion Attic•-� g— ------------------- p ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons.-_______-_--__-__-_-_-- Showers ( ) — Cafeteria ( )
QOther fixtures -------------------------------------------------•---------------------------------------------------------------------------------------------------
W Design Flow......................................:.....gallons per person per day. Total daily flow---------------------------------------..---gallons.
WSeptic Tank—Liquid capacitv �L"�!.gallons Length________________ Width................ Diameter--!............. Depth.-..--._--.-.---
x Disposal Trench—No.............___...... Width-------------------- Total Length..._--____.______--- Total leaching area--------------------sq. ft.
3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..._....-.----..-_sq. it.
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---------_--.__-.--. --
f� Test,Pit No. 2----------------niinutesper inch Depth of 'Pest Pit.................... Depth to ground water--------.__--_._-_-_----
Q+' --------------•--------------------------------•-------------------------•-----------------••-•--••-•••••--................................................
ODescription of Soil----------------------------------------------------------------I--------------------------------------------------------------------------------------------------------
x
U -----
w
------------------- --------------- -------------------------••••-------------------•--•-•......------------.---------------------------------------------------------------------------------------
U Nat e of Repairs or Alterations—Answer when applica le-----------------------------------------------------------------------------------------------
.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Di osal System in accordance with
the provisions of Article XI of the State Sanitary C —T undersigned fur a re not to place the system in
operation until a Certificate of Compliance has been y t board of he
Signed- ------- ••• . `----•-•• �/-.��
- -- ----------------------------------- --------------------------------
- Date
Application Approved By-------�y� x-- ;;W;......... -----'-'�f�-�./',�j'-_-- '��.�" % 7_
(_..----•-------Date -------------
Application Disapproved for the following reasons: .......................•---•-•---------••.....-- --...•-•--•-••- -•--•-
------------------------------------------------------------------•--------------•--••-------•----------------••--------.•_..._...•-•-••-----------------...------------•---•------..._•----------•-•---
Date
PermitNo........................................................ Issued.......................................................
Date
1
7
—04
No. Fps....... ..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
*" ....._....OF.
.... . - „.........................
Aplrliration -for Bitymial orkfi owitrurtion Vrrui t
Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
------------ ----------------
Loc n ddress Lot
W Owner - Address ���
Installer Address
Q Type of Building Size Lot............................Sq. feet. j
U Dwelling—No. of Bedrooms---------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
pi Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria
a
Q Other fixtures ----------------------------------------------------------------------------------
W Design Flow.............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacit W--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______________________
W --•-•- ............................................. Date..........................
Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water-----------_-___-__----
(� Test Pit No. 2________________minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
--------------------------------------------=..............................................................................................................
ODescription of Soil--------------------------------------------------------------=---------------------------------------------------- -------------- ----------------------------------
V --------------------------------------------------------------------------=-------------------------------------------------------------•--•=----=--...-----------------------------•---------------
W
U Native of Repairs or. Alterations—Answer when a plica,1 -----------------------------------------------------------------------------------------------
.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage D• osal System in accordance with
the provisions of Article XI of the State Sanitary C — T undersigned fur a re s not to place the system in
operation until a Certificate of Compliance has been y t oard of he i.
• Signe ........... ..............-•-
e
Application Approved By....... .- ----- --- _
Date.—,
Application Disapproved for the following reasons______________________________________
....................................................... ----•----._._...--------•-------•_---•-•-•--._.....
-•--•-------------
Date
PermitNo......................................................... Issued........................................................
Date
THE-,.,COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................:................. .....OF.................................................................................
'WrIprtifirate of f 41ftwhanrr
THIS IS TO CERTIFY, ,That the Individual Sewage Disposal System constructed ( ) or Repaired
.. 3 = '
by �'?�- _-----------
fi,.. N p Installer r"""
r _______ 4___.._- _________ _
has been installed in' accordance with''the provisions of :Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No_________________________________________ dated-------------------------------_................
THE ISSUANCE OF THIS CERTIFfdATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUN61f1O1il SATISFACTORY.
DATE---------
--------•------..... Inspectorw.. .- --- --------- ----- o ,
,.cJTHE COMMONWEALTH OF MASSACHUSETTS
1. s.
BOARD OF' TH
-�7 ............. ... ~..4-tuo %............... .... 1.,,�' ............
...----•--------------
,
No------------ ----• � FEE........................
Bispo,ial No TT 0 t�rurtion rrmit
Permission is hereby granted '= - +�»
to Co>j5' ct-( )' o` Repa• ) an Ivi ual wage Disposal *7e
J
at No. "'..
- • -• - "
Street i*
4007
as showj, on t ie pplication for Disposal Works Construction Permit No zte _-__________ ________
`.
♦ f
� Board of Health -'__-•••-' -
�
DATE.....................��(
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