HomeMy WebLinkAbout0019 PADLOCK LANE - Health (2) l9 A Amt, lie, Cent,
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No.......1--.......------ t t 9MASSACHUSETTS
F$$..... ............MONWEALTH
\\g BOARD OF HEALTH
1 � 1
_.. __ ... . .....OF..................................... . . ..........................
Appliration -for �i� uittl orks Cnu�t #r r t�rn rr i
Application is hereby made for a Permit to Construct ( 7or Repair ( ) an Individual Sewage Disposal
System at:
n-Address �� o Lot No. '
WT
Owner Address
WjTof
q Installer Address
U BuildingeeC,(s�/G•- Size Lot____________________________Sq. feet
welling—No. of Bedrooms-----�____-----------------------_Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ---__-__.-_________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures ------------------------------- - -
w Design Flow------ _____________________________gallons per person per day. .Total daily flow..........J�-60--___--___--_---.---gallons.
WSeptic Tank—Liquid capacity-1.600.gallons Length................ Width-.___-......_.. Daamn�er__..._.......__ Depth---_...........
x Disposal Trench—No...1______________ Width_jotal LengtlQ2�a�t Y�eaching area__.._..._.._....__..sq. ft.
Seepage Pit No------_------------- Diameter-------------------- Depth below i let--------------------
-TTotal lea liiiig area....... ---------sq. it.
Z Other Distribution box ( } Dosing tank
'-' Percolation Test Results Performed by.._--..`------------- ___ Date_-_______-.-__-__-__-..._-_----_.--..
a Test Pit No. I----------------minutes per inch Depth of Test Pit.................... Depth to ground water...-_---.-_---.--.--_--
�14 Test Pit No. 2................minutes per inch Depth Test Pit-------------------- Depth to ground water------------------------
P4 --•-------------------------- ---•-••--•-----........................................................
Descriptionof Soil......................................... ---•- . ----- - --------- ---------------------------------------------------------------------------------
x
c,
w
U Nature 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 NI of the State Sanitary Code—The nders- ed further agrees not to place the system in
operation until a Certificate of Compliance has n issued by and o ea .
e --- ---• - ---- - •- �- Y•---_....
------- -------------- ---- --
r / / Date
Application Approved By------------ - ` { 7
_D to
Application Disapproved for the following re s ns:.............-...........................................---.....................................................
---------------------•-•-••-•-•---•-•-----•--•---•--•---•-------•-•-•------•--------------•--•---•--=-----•-------------•-••----•--------•----•-- ----------------------------------- ----------
Date
PermitNo......................................................... Issued....... ���..................
No....... .......... Fps. �✓............
THE COMMONWEALTH OF MASSACHUSETTS,
BOAR® OF HEALTH
OF. .........................
� firttti>aa� -for 13iiipasal Works Cnomitrurti n Vrrufit
' `Application is hereby made for a Permit._to Constuctw(. ,� . epair ( ) an Individual Sewage Disposal
' System at
•-o-•Lot No. x
. ` ,�,--------•l - � -�-/ ' '�'+r`-�♦--,�
i
Owner Address :,d
r„
' nstaller Address
UT o Building g %�.L./ (}+ Size Lot...........................Sq. feet
Dwelling—No.,,.of Bedrooms.-.___s,.» E' _______________ ________Expansion Attic`( ) •- Garbage Grinder ( )
Q, Other—Type of Building ............................ No. of persons.-.-_--_---__-__-_-____-.-. Showers ( ) — Cafeteria ( )
Other -:rtures
---------------------
W Design Flow__-__. Q__________________________ gallons per person per day. Total dilly flow.,.......... _:_------------------gallons.
g Septic Tank—Liquid capacity-/_QQQgallons Length..__; ____. Width-. D-1m er_:_-_-- .-- ..... Depth................
W Disposal Trench—No.___ _ Width_ otal`.Len tl aching lrea____._._ . .___s ft.
x P ------------- / g g q.
Seepage Pit No----------------- Diameter------------- Depth below i let--------- :____: Total lea lung area.-_-_.- -.-.__--_sq. ft.
z Other Distribution box ( ) 4.• Dosing tank ( ) , 0 G i� ,.•�'
~' Percolation Test Results . Performed bY-----=--------------------------------------•----------_--------------•- Date-•-•------------------------------------
r •
Test Pit No. 1----------------minutes per inch ,Depth of Test.Pit-----------_:------: Depth to ground water—-----:_.,::..-._----W.
rL, Test Pit No. 2.................minutes per inch' 'Depth' Test Pit:.___ ._..__.-.-___ Depth to ground water..........................
a - --•-•..............-------••------• ------
Description of Soil. -------------•-•-----•-- --------- _... : ---- ---•--
U -------•--- •--•-----------
- w
W i
U` Nature of Repairs or Alterations--Answer when applicable..--_--_._.__I_________________________________
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State Sanitary Code—The ndersi ed further agrees not to place.the system in
operation until a Certificate of Compliance has n issued by b and o eal
Date
Application Approved BY ----------- -- - . ..`.... - e;' •.:
................
Application Disapproved for the following re s:..: .... . ------. = =
---.._...--•-----•--------------------------•---------------------•---------------•----•------••----------••-•---------'-----------••-••-•-•--•----•-----••----...---•'------------•----------------•---
Date
PermitNo......................................................... ' Is"sued.......................................................
Date
• ' -doh" :F� �
THE COMMONWEALTH OF WASSACHUSETTS
BOARD OF H ALTH
l
� P
.
Tutifira#r of Tomphaurr
T IS TO CERTIFY, t the Individual Sewage Disposal System constructed ( ) or Repaired
by__ --• --------- • ...
------
at•-•-•- _ .... nstaller • .-!i/ � dl_ `
has been installed in accordance with the provisions off Art The State Sam ar ode s descr` in the•
application for Disposal Works Construction Permit No-------------- dated...--- /
_: ...........�_:..__
THE ISSUANCE F THIS CERTIFICATE SHALL NOT BE CONSTRUED AS tEE THAT THE
SYSTEM Vr/ILL F W N ! T ACT RY. ! r
DATE.-- ------ ----------....................... Inspector r �'
- THE COMMONIR/EALTH C7F MASSACHUSETT$
_.
BOARD PF HEALTH
OFNo........1.112..— •._ - IFEE._/ ...........
; 4j
Di pail orkiA . .........
r#ion Urrmit
Permission is e y granted__':_ ._ .:..
to Constr ' or Repair ) I ivid SSyste'
at No._. -,-,
G " I Street
as shown on the application' for Disposal Works Construction Lit No...4_______: 7.y____.___. \,
e ----- . ..
- - _-
L ' ,Boar of' ealth !•
DATE � js" �
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS