HomeMy WebLinkAbout0123 PLEASANT PINES AVE - Health (2) �� e� 4Ve� .
00
No....2P....y Fic.. ......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
��.�
OF....................... ..................................... .........................
Apphratiun -fear Biipuiitt1 Workii Tomitrnrtion Vaniit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
//e,
Location-Address Rr Lot 1 1 1
�( ........
...... �................................ �`��l 1� ,�.1`n.A .l..a....V`���--_��!�I''1ou
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms__._.___.a. ...........:....Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building t _Q Q_C -_ -No. of persons------�................ Showers ( i ) — Cafeteria ( )
Otherfixtures ------ - .................... ------------------------------------------------------------------------------- -----------.--
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter................ Depth----------------
x Disposal Trench—No. .................... Width-.--__--_-_-___-__-- Total Length-------------------- Total leaching area--------------------sq. ft.
Seepage Pit No........I........... Diameter._ .Y----- Depth below inlet------V......... Total leaching area------------------sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by------- ----------------•------•--••--••.....--•-•-------. --- Date-------------------------- ........
,a Test Pit No. 1................minutes per inch Depth of "lest Pit.................... Depth to ground water...-------.--__--_-----
44 Test Pit No. 2................minutes per inch Depth of Test Pit-__-__-_-._._______- Depth to ground water.-._.-..--____.-___--...
----------
- - ------------------------------
O Description of Soil. - -- 1
U '- -----------------------------------------------------------------------• ......................................................
-----•------- ---------------------------------------------------------•---•--•--------•-----------------------------------•--------------------------
Nature of�Repairs or Alterations &swgr when applicable.. VN- t ►.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanita�beoefie
he un ersi ed ther agrees not to place the system in
operation until a Certificate of Compliance has y th gar oe th.
Signed .. ....... ----------------------------
Date
-•-- ---- --------- ---- ----
Application Approved BY °A --------------`I--"------75-----
Date
Application Disapproved for the following reasons__________________________________________________________________________
---------------- ._------------
-•-•---•-•-------•------•---•..............•-•---•--•-----------.._..----•------- -•-•----•--••---------•-------•-•------------------------------------------------------------•-----------------------
t� Date
Permit No...........3U.el-------------------------•---.... Issued.......��._��__7�.................
Date
� d
No......................... Fas.-. ...:.�G......._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.r. ................... ............
Appliratinn -fur 43hipotittl Workii Tomitrnrtion Verntit
Application is hereby made for a Permit to Construct (' or Repair ( ) an Individual Sewage Disposal
System at:� (� n
"
J Location-Address or Lot No.
-•-1........................................ ••------- - --•---•
-0-yvner Address
1.4
P4 Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms---------.�... ............................Expansion Attic ( ) Garbage Grinder ( )
A4 Other—Type of Building ..:-. C C?t p ( ) ( )
_....... No. of ersons....----�----------------- Showers i — Cafeteria
dOther fixtures >; '` S ' `
W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length---------------- Width------------.... Diameter---------------- Depth................
x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No--------..-__._.-_-_ Diameter_Y_"_V_--.-_ Depth below inlet.......1........... Total leaching area------------------sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date---------•-----------------------------
a Test Pit No. 1................minutes per inch Depth of "Pest Pit.................... Depth to ground water.._.__............._-
fi Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water..................
---------------------------------------------------•-------------------------------------------------------------•----------------.------------------------
ODescription of Soil............................................................................................................-...-.......---•-----------------------•----•---------------
x
W ---------- --------------------------------- ------------------------------------------------------------------------------------------
----------------�D Nature of Repairs or Alterations—,,Answer when applicable... -.} S'.\r.\� .L_..._._. C_ "�r_.�. - :.. a' ai.
_ N
-----------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issue by thpboard of/ealth.
12 .
=• mot�c�.4 '--------------------
`/ -�
Signed----------------------------=----�----- v •--•- ------=�'�-�•----- .....
Date
ApplicationAPPlication Approved By -J--
5�
Date
Application Disapproved for the following reasons:-------•...................•--•-----------------------------•--.......------•-------•---------------------------
--------------------------------•-----------------------------.---•------------•-------...------------.._..-.....-------------------•----------------------------------------•--------------------------
Date
PermitNo.-•--•-..:.-3/................................. Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS y
BOARD OF HEALTH r'=`tti �' " ' '=` S`- `f .
Ir
QPutifirate of QVI'nmpliatta
THIS IS TO CERTIFY, That'the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by---••........ ............... rt C
? ll Instaer
f f J
at------..... �------------------ -------------�---'---------------------------
---
�'
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.......... f...................... dated........... .............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
7 .
DATE.--••---•---------------- ------�------------------------------------------- Inspector---------------------------------------------------------------------....---........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................... ......c is......O F.._.C�. �� •..'.../..-4-...........---........................
. . . .
No..... .................. FEE ..................
Ui po.5al Norkfi CIlamitrnrtuan Vrrntit
Permission is hereby granted-__-._-_--f_r--.----�--f� _________
to Construct ( ) or Repair ( ) an Ind' i ual,$
��� ewage Disposal System
/
at No.......��----------/ALL t
Cc A
Street
as shown on the application for Disposal Works Construction Permit No.---.-�.� I.......... Dated_....._5..:.._ r'1 _ �r
------------------------------------------B.oar. d- of He-H.e a It
DATE......... ^--� ---..'--------------------------------------
B
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS