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Home My WebLink About0189 PATRIOT WAY - Health (2) I �q3 /19 V III o THE COMMONWEALTH OF MASSACHUSETTS SOAR® OF HEALTH oF..... .Y.S.f � -------.......................... Apptiration for j!Wpoiiai Workfi Tnnotrnrtiun Vamit Application is hereby made for a Permit to Construct () or Repair ( ) an Individual Sewage Disposal Sy a . '� L� a6 ;��, ��fs uJ . ............ u 6_ll .......... ... - ................................. ........ --..... .... ------...--- .. o 'on- ddr ss or Lot No. -------------------------- u a 1`'--------------------------- ----- . ---.--..........---------....................... caner dress ---•--------------------- = 1 ��; ., ,c��.---.----.-- •-------.--.--. �- _ ..... -e��1 ............ Installer Address / QType of Building Size Lot......Z_J r6...Sq. feet U Dwelling—No. of Bedrooms.....;0_0_ef ______________________Expansion Attic (40) Garbage Grinder a aOther—Type of Building�° G'! _ No..of persons..... ................... Showers (q2) — Cafeteria (ue) Otherfixtures --------------------------------------------------------------------------------•-- W Design Flow............................./_/ -------gallons per person per day. Total daipy flow..................... ._ ..4.....gallons. W Septic Tank—Liquid capacity44w.gallons Length__(.-__.. Width.5........... Diameter_-.-S......... Depth---Sy. _._._ x Disposal Trench—NoX..... ....... Width................... Total Length.................... Total leaching area....................sq.ft. Seepage Pit No........�- Diameter.._t ____________ Depth below inlet....--to........... Total leaching area-! -----G-----sq. ft. �/ Z Other Distribution box 00 Dosing to ( ) �Al '/ 7 1l ''' Percolation Test Results Performed by.................. ------ _.____ Date..... ,aa Test Pit No. 1....._d��.__-----minutes per inch Depth of Tes Pit------ Depth to ground water_._..._.®. '___- Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ........ >------------------- Descriptionof Soil •---•----------•• ----------- ---------••-. -•---•--•--••--•----•-----•-•------.....•---•-•--------•----••••---------...•... x �'y Z .............................................. W -------------------------------------------...... -•-o-`- ----- UNature 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 iiT iE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the o rd of health. igne -..... 1 ............................. ----�-I...... ?... Date Application Approved B - ��/�� Date Application Disapproved for the following reasons------ -----------------------------•-------------------------------------------------------•---.........------ -------------------------•-•-----....--------.._.....--------.....---------...._..•..........------------------.••••-•-----------•-•-------------•---------•--•--------••------------------------------ Date PermitNo--------------------------------------------------....... Issued....................................=.................. Date THE CPMMONWEALTH'O'F M'kS 11 SACHUSETTS BOARD* OF HEALTH ... .. OF......................... ...................................... .. . ................... Appliration for Disposal Works Tonstrurtion "rrmff V Application-,is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ' r ............................C.................................................................... .................................................................................................. Location-Address or Lot No. ............ ---------------------------------- ........................ .................................................................................................. Owner Address ....................................................................... ................................................................................ Installer Address PQ 4� Type of Building Size Lot...1J(q_"_')5'46-------Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( ) Otherfixtures ...................................................................................................................................................... Design Flow............................................gallons per person per day. Total daily flow....................... ....................gallons. $Y4 Septic Tank—Liquid capacity------------gallons Length................ Width................ Diameter._----__---.--._ Depth.....__..__..... Disposal Trench—No..................... Width........_...._._.... Total Length_-__................ Total leaching area....................sq. f t. Seepage Pit No..................... Diameter.................... Depth below inlet_................... Total leaching area..................sq. f t. Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......... ?ke'/'r Date...... ............ �4 ---*-------------------------------------- ------- 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...-__........_......._. ............................................................................................................................................................ 0 Description of Soil..........................................2 K--------------------------------------------------------------------------------------------------------------------- ....................................................2.................-....................................................................................................................... U ....... .. .............................................. ..................................................... --------- ............................................................................ Z 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 TLITIL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. igne ................................ ----------- ------I ------- Date Application Approved By......... .............. ..... --:?Ie..... Date Application Disapproved for t e rfoll6wing reasons:................................................................................................................ ......................................................................................................................................................................................................... Date PermitNo.................................. Issued-............................................................................ Date THE COMMONWEALTH OF MASSACHUSETTS I BOARD OF,I,H,EALTH '41 iy 1� .........................................OF.... ..................................I...................... Tntifiratr, of Toutpliaurr THIS IS TO CERTIFY, That the Individual' SewageDisposal System constructed (�') or Repaired by......................I.,-...'. ................................... Installer_ �?"V/ , I ...............................................------ at......... ......... ........................................... ........ .................................... has been installed in accordance with the provisions of TI 5�o�Thr_ 4ate Sanitary Qde as described in the dated......X..----- ...40.......... .... A&V--- -------------- application for Disposal Works Construction Permit No. _�ZV. THE ISSUANCE OF'THIS CERTIFICATE SHALL T BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.............. Tir -----P-C-00 .-...................................... Inspector ............................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH nn.............OF.... A- -----......................... No...........(40 FEE..�J.............. 7M Wisposal'. orks 05 n' Wn ;Irrmit Permission hereby granted.............. ............................... .................................................... to Construct (X V, or Repair Individual -59wag DDispo al System .......................at No.. ...................................... Street as shown on the application for Disposal Works Construction Per Dated._ _--_'/s.....7j:..*...... • % -.. ...... ..... ------------------------ DATE.. Board ealth 0 le,-"4-------- FORM 2 55 HOBBS & WARREN, INC., PUBLISHERS k _ " L 32I3-7, Z�26 /1)O 00. .9SSUMa �y •: C� h - - • ._ Y � «z ft``4 �x� '� faµ �r'a�i• ..r•. ' (A �scsr` 9S. 7 65 cl Ex/S ccouN?E EO.'° 1 ' G�B � P/TS //S'S� • LET GDT P.E . 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