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HomeMy WebLinkAbout0097 OUTPOST LANE - Health (2) 47 Crsf- Cn. � Ir7a o94 / No......... . -C� Fims.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD E HEALTH P I , ppliration for Uiipusa1 Works Tomitrurtiun Famit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal stem at .� �r'-J (AW76� � ..........................'�___- ---- -----------•-----------------_---_---•-------- Location-Address or Lot No. AIR) - -------------•-----...---...._.: '... 1�:�'a�.� Owner �" Address d Installer Address Type of Building Size Lot............................Sq. feet oo U Dwelling—No. of Bedrooms........... -___-__ Expansion Attic ( ) Garbage Grinder a """ Other—T e of Building No. of persons...... ............... Showers Cafeteria Other fixtures . _------•-- W Design Flow... ......................gallons per person per day. Total daily flow_-__._ _. ___.__..:____.._gallons. IMP,W Septic Tank—Liquid capacityp. ftallons Length------/n...... Width................ Diameter__-_____-___.._- Depth................ x Disposal Trench—No..................... Width...._.._........... Total Length...................;..Total leaching area------.............sq. ft. Seepage Pit No...... _. Diameter: < 1---- Depth below inlet.....::.......... Total leachin ar ___..: sq, ft. Z Other Distribution box ( , ) Dosing tank ( . � ��.`14- + ` 1, l '-' Percolation Tess-Results Performed b Y :�• Date -- .........--........... ,-a Test Pit No. 1.... .....minutes per inch Depth of Test Pit................°_.. Depth to ground water.._AA!kA1C_. (14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ow O Description of Soil..... � "�� -- ' d =` " _ ..................................Ia Sys . . JA .------------------------•-_._.._....__ ,p _____��_ __.___c _ _ _• �yrr __________________________________________ __.�,�y..._._.._............._-____--_-_--------___--•------______-____.____.----__-___-••----_---_____-------_---__-_---•-•-----_..._....-_.___..._ ►�y ._, . U Nature of Repairs or Alterations—rAnswer when applicable.----------------------------------------------------------------_......__;;_.... Agreement: ` r The 4undersign d agrees to install the aforedescr-ibed Individual Sewage Disposal System it accordance with the pro�,isions of iI.?.i� 5 of the State Sanitary Code-� The undersigned further agrees not to place the system in .operation until a Certificate of Compliance has been issue by the board of health- . Signed= -_ ... '` / Date r Application Approved By...... ..A ------------------- Application Disapproved for the following reasons:....................................... ....._. _....._......_..._ .........-•---•-----------------•----•--......._-----•••--•----•-•--•------------........-•--------••-•-------•------•----•-------•-•-••----•---••--•----•----•-----•-------------•-•--•--•••------•---- Date ------------------•---_._.. IssuecL- --- /�1---.---_ - •---------•---- Permit No................ -'--? �� fi No......... . Fimic ...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL.-FILI ,�,� qqrlAiUlla------------------ Applira#iun for Disposal Works Tonotrnr#iun Prrmit Appl cation is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: -- ..... -' ............... .. Location.A or I o. -. . .' ................................ caner dd a ` ---•--- f�.... �5 '! # re s .. Installer ' �9 Address U Type of Building / Size Lot...........................Sq. feetao Dwelling—No. of Bedrooms............2.......................Expansion Attic ( ") Garbage Grinder Iwo Other—Type of, .Buildin ..ls!'._.._... No. of persons ............. ..... Showers — Cafeteria Otherfixtures. ................................................................................................................. .. ..•-•- W Design Flow... .....................gallons per person per day. Total daily flow...... ...................gallons. WSeptic Tank—Liquid ca.pacrty f allons Length......,...... Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.- Total Length ...... Total leaching area-____ sq. ft. Seepage Pit No....__.............. Diameter. Depth below inlet o leachm ar �pi...sq. ft. Z Other Distribution.box ( ) Dosin a Percolation Test Resulla, Performed b .► _ ..... !NJ . ............................. Date___ p ,.a f/ Test Pit No. I.._: ....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._.___._.............. •-- OxVW . Description of Soil-...... , 14 - -- •--- ----------------- -----••-•-•-. ---- -------- -------- -- ................................... - VNature of Repairs or Alterations nswer when applicable....................................................................... ..................... ------------------------ Agreement The undersigned agrees to install the aforedes, ed Individual Selvage Disposal System in accordance with the provisions of TITLL 5"of the State Sanitary de The undersigned further agrees not.to place the yste in operation until a Certificate of Compliance'has be n issu by the board of h Si he - � Y g • - M._�...� t Application Approved By.....:_ ...._. .. -•------- +..... .......... Date Application Disapproved for the following reasons-..................................... ------------•-------------------------------------------••........._ ------......•....---•---------------•-----•------------------...-•------•--•----.......----•-----------........._....--••------------------------------------------=.................................... Date Permit No. - - Issued / •--- ........................... Date THE CO,MM%kf$ E-AL H OF MASSACHUSETTS BOARD OF HEALTH pow OF....� ., .. .. ..1 .............. Tr fifiratr of Tompliaurr TH S TO CERTIFY Th th ndividual Se >sp 1 System constructed ( ) or Repaired ( ) .. at----- 1 - '. ' .Installer m.� .�.. ----•------•------------------------- has been installed in accordance with the provisions of T 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No............ .. .0................ dated..f©_i.. ..... 7___.._.___........ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. fo, ... Inspector---.••---------- ---......__....-•-----••------•-•-- -.DATE........��-v--••-•-�------./_/_�.�.-----•- - • ---.... THE COMMONWEALTH OF MASSACHUSETTS BOAR F .REACT f/ ............... . " ..OF.....:. . .. .... ....... . No.. FEE .l..! !!m'...... f. iuu 1 or unr to rant# Permission is hereby granted_.__ = .............--\ ...... ------ w.1!. ......... to Const uct or R a r ( an ivldual Sewag Dispos ................................. street . as shown on the application for Disposal Works Construction Pe>a it No Dated___ .......................7 ,a Board of Health _ DATE-------------------- ---•••......•••. •••••------- FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS r .! .... , tAY - �...e Vie.+ '..t..a ✓�.i d . 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