HomeMy WebLinkAbout0059 OUTPOST LANE - Health (2) SDI t!� .� C°9,n��'ru�(f�
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No.......Y-f-I..... ...
THE COMMONWEALTH OF I MASSACHUSETTS
BOARD, OF HEALTH
----------------OF...... .. .... ...
Appliration -for Diiipoiial Workti Towitrurtion Vamit
Application is hereby made for a Permit to Construct -®r Repajram ) an Individual Sewage Disposal
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Lo ion-Address ?o.ot No-
wner 0 Address
........ ...... ............................................... ......... ........ . ..... .. . ---------------------------------------------
Installer Address
Type of Build Size Lot.............................Sq. feet
U C�_ �
Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic Garbage Grinder
----- -----
--------- -----
L. on
Own
er
Other Type of Building ............................ No. of persons._____.._................... Showers Cafeteria
P4Other fixtures ---- ---------------------------------------------------------------------------------------------------- ............... ................
..... --------
Design Flow ................��.AQ Mons per person per day. Total daily flow____----- �a.,d:217V_------_---gallons.
9 Septic Tankfliquid capacit,;�i4i,;ailons Length................ Width Diameter_........_..--_- Depth----------------
-------------- Width--- Width._,__.._
- _'�otal leach*0------ Tot Lent leaching area----------------_--sq. ft.
.21�4 Disposal Trench—Y
ep el
------ ------
Seepage Pit No------I------------- Diameter./A--- ----- ep el A,inlet-- ----- Totaljeaching area_...-_ .sq. it.
Other Distribution box Dosing tank ( ) of
® P, -5.
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--_-----------minutes per inch Depth of Test Pit..._................ Depth to ground water_-.__._____-__-__..._.
a' - ------------
0 Description of Soil_.--__--.--__-_--_---- ----
U fee ------------
----------------------------------------------------------------- ........................----------------------------..------..
---------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs Or Alterations—Answer when applicable--------------------------------------------------------------------------- ----------------
..................................................................................................................;;---------------------------------------------------------*-------------------------
Agreement:
The undersigned agrees to install the aforedes-cribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitar ode—The undersi d further agrees not to place the system in
operation until a Certificate of Compliance has e n issued by b and healt
gn ..... . ------------------ ...... ...........
Date
Application Approved By----- ..... - --- -- ---- ---7--- ���--
Date
Application Disapproved for the following r . ns:-------------------------------------------- ------------------_7-------------------------------------1.
..........................................................................................------------------------------------------------------------------------------------------------------------
Date
PermitNo......................................................... Issued........................................................
Date
.............. --------------------------------------------------------------
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No......-........ -----• Faiz.-A ..................-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH ,,.
Yt. . .. .......OF......:... ....
Apphratinn -fur Diaposal Workg C owitrurtion Vrrmft
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
LS tion•Address ! � t No
w.,,.
•- --- -- --�..._ __i--- -- � --- .1.. .... _ ac_- ---�""-- •-- -- ...... •---'k4. .-.• --- -•-----•----- ------•--
Owner Address
��
W w !
Installer `-. Address
d Type of Buildf/"tn s' q
U ,,. Size Lot.... _: ._._____S feet
Dwelling—No. of Bedrooms____ ________ ________________________Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ----------_----------------- No. of persons:-_____-:-:____-_._-_______ Showers ( )' — Cafeteria ( )
a
Other fixtur s -- v� -----------------
W
' Design Flow_:_______-e.._.. ._.__:_:_ allons per person per day. Total daily flow________'!�__ �: '... ..gallons.
Width....... ....... Diameter-------------- Depth----------_---
Septic Tank Liquid*capacity _. . _:gallons Length_______________
x
Disposal,Trench— o----_________ .... Width.- __ Tot �Le*figtlVotal leaching area--_--.___-_.-._____Sq. ft.
Seepage Pit No.___. :_.._:-. ._ Diameter _.. ept elet_______________ _ Tota 'eachiug area_ __: , ____ __Sq. ft.
Z. . Other Distribution box { ) Dosing<tankI r,
aPercolation Test Results Performed by,----- . .. :.. .................... ________ Date_' .._.-
,� Test Pit No. I_______________minutes per inch Depth of "Pest Pit Depth to ground water. ..
Test Pit No. 2................minutes per inch Depth_of Te t Pit ._.___...____...._ Depth to ground water_--.___.-_.-_-... .
._._________•_____.. _. __.___ .............
--•-----•___..........................................................
Description of Soil......... . ....__.___ -
W
VNature of Repairs or Alterations—Answer when applicable------------------ ---------------------------------------::_ -----.-_:_. ._-..._---_-. ---
>` -
---------------- ----•--••-•-•-------- -------------------------------------------------------------- - ----------------------------------------- --------
,Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal. System in accordance with
the provisions of Article XI of the State Sanitar ode—The unders' d further agrees not to place the system in
ee
operation until a Certificate of Compliance n issued by b and healt .
-
gn f = -
{ - at
Application Approved By. - Dat'e
Application Disapproved for the following re ns__________________________________R-__.__=- -----=----------_------_-----= �_.-__.__.______________________
•...............•----•-••-•----- ------------•--------------------------••--•-•-•---•----------------•-------------•----------------•--••----------•-------•--------------------------------------------
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
j I
sr BOARD F EALTH
{
�` C�rrtifirttte �f�f�lam�li��rr;
HIS IS TO CERTIF hat the Individual Sewage Disposal System constructed or Repaired ( )
by M L 1 ------ ............
---• •----••------- ---•-••--
.-_... -
has been installed in accordance with the provisions of Article XI of he State Sa itary Cod as de ribed 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 ;y-•-•--•-•--------------------••---•----•-•------------•-----••----=--_.... Inspector-----------------------............................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
LL. '. OF_ ..... ......... :.: ...............
No. FEE__?! -................
Permission is hereby ranted-- ------=-------•----------------------------------- _-----------------------------•-
to Construct ( Re.air ( an I "'duSe g - Dispo ] S �tem
Al
1. Yr+
at No. - --- --
Street
as shown on the application for Disposal Works Construction- it No.. Dated.....::/ 7-7..........
....t------- 17...............I-—
-
Board of Health
DATE '
FORM 1255/ HOBBS-& WARREN. INC.. PUBLI ER$
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