HomeMy WebLinkAbout0223 PINE STREET (HY - Health 0
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD ALTH
/ --------....OF.......... ........ .. .
Appliratiun for Dhipvii al luorks Tomtrurtiun Famit
Application is hereby made for a Permit to Construct (\4 or Repair ( ) an Individual Sewage Disposal
System at
.............................. ......-- ....
Loc 'on-Address or Lot No.
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.. .. �c t� _.,�3.2 i --------- -----------------------------------------------------•.............--•--•----------------•-----...
WOwner s. Address
---------------------------•--•------••- -------••--------------:�`..,SPA/�1 ??/ .1?�............__....
Installer Address
UType of Building Size Lot............................Sq. feet
�-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building laTy 1 _. No. of persons.........Y________________ Showers ( ) — Cafeteria ( )
d Others fixtures . ae//��.1 .. .................................------------- ------- //
Design Flow....... z _----•------------------gallons per person per day. Total daily flow.....
WSeptic Tank—Liquid capacity/s d7`V..gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width........._.......... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No----------_--------- Diameter.................... Depth belo inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ). Dosing tank ( ) -O b- 'pa+•y /K�� y e - 2"2 7'7 F--
aPercolation Test Resu1 Performed by.......................................................................... Date........................................
Test Pit No. L. -------minutes per inch Depth of Test Pit..............._.... Depth to ground water........................
44, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
0 Description o Soil ^® -'?..� _ y1. ..............
x ,1 a=Ist--.---------_--_------------ •-----•••-----•••--•---•-•-•-•---•--•--------•.....................•-•------------
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------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-
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 A IT11 5 of the State Sanitary ode— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has e issued by board of health. -
Signe .. ` �� rs"Z ��/�T
,!
ate
Application Approved BY--.-- �•'ZZ ! -------
-----
Date
Application Disapproved for the following reasons------------------------------------•---------------------------------------•---------------•-••-•-----------
-----------------•------------------------------•----•-•-----.....--•-•------•--•-----.......--•-----•-----•••---...•-•-••-••-••---•------•-•----••----•----------••-•--••-----•---••-----•-------•-----
Date
Permit No......................................................... Issued-. °t .._...
Date f
r
q.
No. - -- •- Fss...... ...._.y......._
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® gF H ALTH
1
OF....... ..............................................
Applira#ion for Di-qVniial Workii Tnntitrnrtinn JIrrmit
Application is hereby made for a Permit to Construct ( V�'or Repair ( ) an Individual Sewage Disposal
System at• _
..... .... ........ 't/..1�/Z. s. ...:_.: J. /.1/_2..... .....--•-•........... ...........................................................
-••-
Locati Address G,: or Lot No.
Owner Address
D................................... ,................................ c ................................
Installer Address
QType of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type T e of Buildi>l vT; o. of ersons............l.............. Showers
G-1 YP g / ( ) — Cafeteria ( )
Otherfixtures '. (� .----�/1 fj------------------------------------------------------------- -----------------------------------
W Design Flow...............................::....._-_.gallons per person per day. Total daily flow----- .........................gallons.
WSeptic Tank—Liquid capacity/ ,D.V-gallons Length............... Width................ Diameter---------------- Depth................
x Disposal Trench—No. ..................'... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter-------------------- Depth belo inl t................._.. Total leaciling�area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) ' a'�'Mf7lr'" ' F 7�
aPercolation Test Resul s Performed by........................................................................... Date........................................
Test Pit No. LA........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........................
,p
D Description of Soil. � � � R �'= - °I. `�I- --------------------------
� � . .. T,�` s��.i� �P
.....................
v ----------------- ....... , ----- --- 1,S��X. . .,...................................................----------------- ---------------------....................
....................................................---------------------------------------------------------------------------------------.............................................................'
UNature of Repairs or Alterations—Answer when applicable...................................::..........._.__._.._..___..._..............._..............
...= s.
Agreement
The undersigned agrees to install the 'aforedescribed Individual Sewage Disposal System in accordance with '
the provisions of TITTIE; 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.
Sign d _
Date
Application Approved By---- . ._. ................. '`�- .....................
Date
Application Disapproved for the following reasons------------------------------------------------------------------------------------------------------------•••--
.: ........................................................................................................................................................................................................
- Date
Permit No...........................
------------------------------ Issued._...Z.`•2:Z`'�__`:..0.._.. .._ . .
f
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
........�:1.. ................OF.............:..:: .."..y.:...................................................
(Irr#ifiratr of Tomplianrr
THINS ., C RTIFY, ate h Individual Sewage Disposal System constructed ( /_�or Repaired ( )
..........................................
1�f Installer.
...MZ. n .................................I.........
has been installed in accordance with the provisions of TI 5 of he State SanitarA
e as d ,scribed 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... . .' - -`7 Inspector-- ...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HE H
7 b'
_... ........................... r
.....t e-4�-
..............OF......... ......No FEE.
.......................
ui vo r Cann ; ion ami#
Permission hereby granted `-- •---------------------W".= ------ .......
=..._..
to Con ru ( ) or , epair ) Individual Sev�age Disposal S�` stetn
atNo.------ -•-� ------- :..... ..... "............... . _�?�` �-= ------ -----------------•.... ...•--•--
y
--- eet •�..+ v f �s
as shown on the application for Disposal Works Construction Pe m>/t' No__ ________________ Dated....__.__.I
............................
+' .y .._ ._. < ....... ............... ....
DATE....�:.__�A-Z�...: ............................... a Boar alth
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS /
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