HomeMy WebLinkAbout0903 PHINNEY'S LANE - Health (2) �03 Ph l nneq s Cax►e, .
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
..._......OF.. + ' 1d -----------------------------------
N. ...... � ni��rXVp ration for llhipvii l nrkfi nnntrnr#inn.
.. Y
Application-is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System
.............(i...G3 � ... `.... .........................................r.............
Looff n-Address or---Lots�Tg. C».r1
d��..: r.................................... - t .4i'. dam!,z.......'C.�•'�....
Owner f Addres P "
a �.f Q l.__��/.���- ..................•-•------............------ ...._ --� ...-... l T !��
Installer Address
QType of Buildin'gs� Size Lot............................Sq. feet
Dwelling-6�No. of Bedrooms__--- .......................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures -------------------------------•---.._....--------------------------------------=------........._..-----------------------------------•-----•---------
W Design Flow.................................X.6rgallons per person per day. Total daily flow------�:.�-.-_______.___--__---._-_gallons.
WSeptic Tank—Liquid capacity..fk2r->_gallons J,-ength-------------_ Width-_ ____---__ Diameter---------------- Depth................
x Disposal Trench—No_________________ . ______ Width..... ...____.... Total Length..... ......... Total leaching area...2-d_/-----sq. ft.
Seepage Pit Now.../ Diameter____________________ Depth below inlet.................... Total leach' ea........._.......s . ft.
Other Distribution box (� Dosing tank
~' Percolation Test Results Performed by-_- 1- i-t
r.�J.40 Date__.._Test Pit No. 1__...i......minutes per inch Depth of Test .................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground.water........................
a --------------------------------------------------••-- ......_......_... ... ---•--... ..--•--............
O S- ------. r
Descript n of S II--------_...A' .�c�( '� ....
W ............. '+�+� �.--- _____!.........................•------ ------...------------------------------•-----------------------------------------------------•---------
-----------------------------------------------------------------------------•-----------•-•-----•-------
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 T I T 7 L 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ' u by`tthe board of health. q
Date
Application Approved By----• ----- 1LIJ�l �°----�-` ..... .----
Date
Application Disapproved for the following reasons-------------------------------------•--------------------=---------------------•--------------------..........._
•-•----------------------------•--•-•-----------....--------•----•------......----------•-------......---------------------•----------------- ------....-•--------------•-------•-----------------------
Date
Permit No.. Issued. .7/------.......................................
Date
No--------------------•-- F> s...��.......... ..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
App irtttiun for Diupuuttl Works Towitrurtiun rrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
✓0 w �I S.r. X.. ... ti2''CJ ....!JW/ir ....../1!A............................................................
• ---•--.. 4ar- -
L'ation•Address or Lot
--
- Owner `� Address
,er-----------------------------•-•--•--.....-------- ........ j '---'-- +r.. .._ i? i ...............
Installer Address
U Type of Buildin Size. Lot............................Sq. feet
Dwelling7No. of Bedrooms____ 1 _______________________Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ....... No. of persons............................ Showers — Cafeteria
a Other fixtures ...............•-------•-------• .
W Design Flow...............................w_S":3 gallons per person per day. Total daily flow_-___-A_.40..........................gallons.
W Septic Tank—Liquid capacity_ i.-y.. ?gallons 'Length---------------- Width_____________ Diameter................ Depth_....__.._......
x Disposal Trench—No..................... Width......,_'_...._...... Total Length.-_....__ .._........... Total leaching area.-- ...... ft.
Seepage Pit Nc6.4-eft"_.1. Diameter-------------------- Depth below inlet.................... Total leach--ingsare�_,._,_;_ti._�sq. ft.
z Other Distribution box Dosing tank
'-' Percolation Test Results Performed by:_., ea ,fir'a '. )�,r.b�. jc-dM_.._..S�fl.f� Date....46,..
Test Pit No. I.....9_......minutes per inch Depth of Test Pit.................... Depth to ground water...........^.........
...
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a -•-•----•----•-........................................... ._..... ----•-------........
p ' a - s - dT — I z _ i�; � ---------------
DescripLon of il-........ .r. ur xr �'=-•---------------------------- -------------------------•---------....-----•----------------------------------
V
W ...........................................-•-•••-•--...-•---••--•••--•--------------...........•-----......--......................................................................................
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 T ITIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ' u d by the board of health.
(l —zSate
Application Approved BY .- l._GG' �_1 :..-=--•-••--------------- G/
Date
Application Disapproved for the following reasons---------------------•--•-------------------------------•--------------------•------------------••--------•.---•-
...................-....................................................................................................................................................................................
Date
PermitNo....................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAL .H
lt- :?.........oF........... .......- :... -...............:..... ................
�rr�ifirtt#r of f�u�t��ittn�r
THIS T� E f_I. Y, That the Individual Sewage Disposal System constructed ( or Repaired ( )
by........'. .-,.-----.�(.�,r .'� x..................................................... '-....... ............ ............................................................
Install
at =- l '� ,t /--�1�Z `'� � ` �G�2� = --------------------- -------------------
has been installed in accordance with the provisions of T �1 /The State Sanitary ,�1e,2a de
seibed in the
application for Disposal Works Construction Permit No._ __K ............................ dated_-------- .....................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL F NCTION SATISFACTORY.
DATE.......... / Inspector....
•
. THE COMMONWEALTH OF. MASSACHUSETTS
�—. BOARD OF HEALTH
...
No......................... FEE........................
Biupuuttl Work trudiun an it
Permission _hereby granted.............................................................•-•---••---•---• _
to Construct ( ) -or'Repair (( ) an In' •vidual Sew e > posal .ystem
�Stree€.
as shown on the application for Disposal Works Construction Pe>mit No._c__.__ �; ?- Dated------------ -•-.---_---
-•--------..........--- - ................ ...............................
•------ ............................. Board of Health L
DATE------P�--�-'•----- ~--------
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
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