HomeMy WebLinkAbout0155 KNOTTY PINE LANE - Health (2) l55 �o� Pne r� �i�
THE COMMOJEALTH OF MASSACHUSETTS
BOAR® F HEALTH
... ...................
Apphratiou -for Bhi viiat Warkii C otuitrurtion Vautit
Application is hereby made for a Permit to Construct ( ) or Repair ( �_an Individual Sewage Disposal
System at:-,.
--------- ----S..I---•-•--------------- ----............................. .......................... .................. ...........or Lot No
Dr• .. ........•. -- . ../-=-W Q.: ._._. 1 --- --•�-� ----- -------
ow r ress
p Installer Address
UType of Building Size Lot............................Sq. feet
a Dwelling—No. of Bedroor3ts-- _._.__................... -------- Attic ( ) Garbage Grinder ( )
per, Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Q' Othei _ ures --•--------------------------- - -
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 ( )
aPercolation Test Results Performed by-------------------------------------------------------------- -------- Date---------------------------------------
,� Test Pit No. 1----------------minutes per inch Depth of "lest Pit--------------------- Depth to ground water...-_-__--__-._-_-...._.
�TA Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-----------..__.__-_-__.
Ix -------------------------------------------------------•----•---•---•---•---••---•-•-•-------•----.........................................................
0 Description of Soil------------ ------------------•--•---•---•-•-•----••-------•---•---••-•---•----...--•-•-••-----•---.....-------.----•--------------------------------------------
x
U --•-----------•-•-------------------------------------•-----------•---------------•-•---------------------------•-•-------_---------•--------•-----------------•-----..................................
--------------------- ----------- •-•-•--------.-------••------------•---•------------------•--------- r---•--•--•----••-•• - ••• - �L-
V Nature of Repairs or Alterations—Answer when applicable._ -___--. ---
.._ �..
r `
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disp al System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned rther agrees not to place the system in
operation until a Certificate of Compliance has een issu by the o%dealth. 7
Sign J�?L J ",
- ---
Date
Application Approved By-------- ----- ------ . -• . ----- - ---- ------ .�. - 7-X.
�Dat�
Application Disapproved for the following reasons:...............................................................................................................
-------------------------------------------------------------------------------------•------------------------•--•-••--•------------•-••---•-------•......-•---•----------•---_._...........------•--••-
�� Date
PermitNo......................................................... Issued...... .........................
Date
No.......... _.... Fns :..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9F HEALTH
Appliration -fox Bi_gpmal Worko Tonstrurti n Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( /ran individual Sewage Disposal
System at• ,I^j
�j /' -Q
f Lo ar C-L1Fidr ,s or Lot No.
.........Y 3t a.,.» y
x Ct ► ' -�.�._� ._. 1 _, ---- ._.. f, ` � '�` W fit '®„_ �?
�� .. . �
OW r� Address
Installer Address
d Type of Building Size Lot----------------------------Sq. feet
U Dwelling—No. of Bedrooms___________________________________Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
P I Other fixtures ------------------------------------------------------
W Design Flow--------------------------------------------gallons per person per day. Total daily flow.............................................gallons.
P4 Septic 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. It.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date--------------------------------------
Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water-...___--_____--_----..-
�14 Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water............-_-_____--.-
P4 ---------------------------------------- -----------------------------------------------------------•----•---------------------------------------------------
0 Description of Soil-----------------------------------------------•-----------------•-----------------••--•--------------------------------------_____---------------------------------
x
W -•----••-••--------------------------------------------------__-••_. . 1 ------•-----------------------`------- ----
VNature of Repairs or Alterations—Answer when applicable_f.___ _ :. _ .r-..._._. e _
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disp- al System in accordance with
the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has een issued by the oard of-health.
Slgrie w r7al......................................' ' t /r`7r';* *�f
-i
Date
--------
Application Approved B �_ ___ � t'r:._. ' ----------------- - - -- _ _7-
Application
PP PP Y v -�---------------- v - -� ----, f f
Datd
Disapproved for the following reasons: ------•----------------------------------••-•••-•••---•-•----
-••---•-----•-••--••-•-...•-----•--•--••-•••••---•------------•-----••-•••-•-----••.._..•-••-•-••--•••••-•--•-•--------•-------•--•------•----•--•-...•--•-••-•--•--- -----•---------•-•---•••--•------
Date
Permit No......................................................... Issued........ �—� .... ------
ate
1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�Z7
Tntifiratr of TlImpliaurr
THIS I° TO CERQFY, T t e Individual Sewage isposal System constructed ( ) or Repaired
/ Installer
�y . ; ,. � a __9 '��� •-•------- -• ------ ---at_..- = ................~(
has been installed in accordance with the provisions of Article Yj o ,The StaVSanttary Code as de cribed in the
application for Disposal Works Construction Permit No____________________ ________________ dated.-_-'f --I...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WIL UNCTII N SATISFACTORY.
DATE -3��---`-- - Inspector---
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-No......(2.:_ ........ FEE-' :................
R-rivalialNork �n tr rtioat I mit
Permission is hereby granted_____-._._ .__ .__:__ :_____..:_..r --� ....._._.-_
to Construct ( ) or epa.i �' an.I dividual ew Disposatl�Syste -
-- - /
at No.- w
v Street
as shown on the application for Disposal Works ConstructioIn Per -it7o._..._.._c' .._.r Dated___'7/_�- _. _..._
v"' �� �
�fy ....................
Board of Healthf
DATE.._... =----•----•----'- - -� �^/----............................... •
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS