Loading...
HomeMy WebLinkAbout0223 PINE STREET (HY - Health 0 .r . 77 , 7 02 y .. J 1 F� ...2.5. ....._ g, No................_..... 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. . i � N24"4�,Q".1 .. .. �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--.---------_--_------------ •-----•••-----•••--•---•-•-•-•---•--•--------•.....................•-•------------ 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 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 / �� +� 'fib P�-� '�,�- �'•s.t�j�. �.� t i4 AN P oN Ihss LT?N6 �r1 fy, hGs 4 9l44T 35 - � '97 haw ��e F I w 6k.. TP d 2 ►y _ !o x(ors Goo -. 44 0 1 pa&p'l I ell NO I ` . t�s'rF�'Snx w N�• Pf-, etc• 16,75 A'/, MAC. 12.-M - a � �µ I�eIFM ,tABpIUIX Tb ASUTW j'.G•CLI IG } 5�0 'rf i"� ! 'mot' Alm OF �/e# •TO 1 —�_�_Y � �1E� rl N° `r, -t • +3