HomeMy WebLinkAbout0111 POND VIEW DRIVE - Health (2) lll And l/iW br-,j Cei►�-.
No....... •-•'---" Fim...,f11..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEAL
....... ....io -- .OF.....
•
Appliratiun -fur Uiipuutt1 Worko Tomitrnrttun Vrrmft
Application is hereby made for a Permit to Construct ( ) or Repair Ic dividual Sewage Disposal
System at:
j1„_ �( Lgcrion- ss or Lot No.
"-----------
Owner •-•----------------•--•----...---Address
------------
Installer Address
Q pe of Buildj Size Lot----------- ----------------Sq. feet
U Dwelling—No. of Bedrooms.............................. . . .Expansion Attic ( ) Garbage Grinder ( )
p., Other—Type of Building ---------------------------- No. of persons_- _-_------___.-------_---- Showers ( ) — Cafeteria ( )
a' Other fixtures ......................................................
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.................... Depth below inlet_-.----___-..._..--- Total leaching area...-__-.----------sq. ft.
Z Other Distribution.box ( ) Dosing tank ( )
aPercolation Test Results Performed by-------- ----------------------------------------------------------------- Date----------------------------------
Test Pit No. 1................minutes per inch Depth of "lest Pit.................... Depth to ground water.__:___._-.-....__---.
r14 Test Pit No. 2................minutes per inch Depth of /Tet Pit..-........_.-_-... Depth to grou water.-------._..-.-.--------
--------- ------- •---------O Description of Soilz --�----- -------------- ---'---------------------------------------
x
------------------------------
W ------------ a--- -- - ----- ----------
--------------
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 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 issued by the board of health.
.�gned------ .....L-- -- __-------------------------------------------------------- --------------------------
Date
Application Approved By---------- --- ----
/fat -------
Application Disapproved for the following reasons:----••-------------••--•------------------tl£7......-._•.-.....---•--------------------•-----
.......................•--•-•--•-••.....---•-•--.......--------------------••----•••-••••---------'-'••--••---•-••-••---••••----......--•••-----'------------.........------•••-•-------------.....-----
Date
PermitNo......................................................... Issued...................... .................................
Date
No.. Fss. � .............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEAL
-oF...... - ----- --. . .
Appliration for Bigplo iia ,arks (inn.4trurtintt Vrruift
Application is hereby made for a Permit to Construct ( ) or Repair }an I divi ual Sewage Disposal
System at:
LPtton- ss of-'.'Lot No.
-4'w.�•
_6�_-
Owner Address
- ----------------------------------------------------------
Installer ;' Address
Upe oQBuildi Size Lot----------------------------Sq. feet
Dwelling! No. of Bedrooms___--- ------- -----•---.-..__.-.--......._.Expansion Attic ( ) Garbage Grinder ( )
pa_I Other-Type. of Building ---------------------------- No. .of persons---------------------------- Showers ( ) — Cafeteria ( )
dOther fixtures -------------------------------------------------------•
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-----------_
No--------------------- Width---------------------- Total Length-------------_----- Total leaching area......--------------sq. ft.
3 Seepage Pit No------------------ Diameter.................... Depth below inlet.................... Total leaching area...._.._._...._._sq. ft.
z Other Distribution box ( ) Dosing tank { )
Percolation Test Results Performed by-------------------------------------------------------------------------- Date---------------------.-----------------
a Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water---...__.._-.._...
(4 Test Pit No. 2................minutes per inch Depth of /Tle Pit..........--...... Depth to group water........._..._._..--..__-------------------- - ------ .... --------•-------------------------- -
ODescription of Soil- --------------------' -------------
- -• --- ---- --A-------------- ---- -----------------
x
UW ----------- -------------------------- --- -----------------..._..-_---...._.---------------
Nature of Repairs or Alterations—Answer when applicable `r As .
---------------- . . -
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 issued by the board':of;health.
aodgned --- ---------------------------•---
---- te
Application Approved By-------- ;.- ----- Date
44
;.: ,
Application Disapproved for the following reasons:................................
•----•-•------------------------------------------=----------'---------------------'---••----------------'------------------------------------------------.._..-..---------------------------------------
Date
PermitNo......................................................... Issued---................... ........................=-•--
Date
THE-COMMONWEALTH OF MASSACHUSETTS
BOARD OF EALTH
............OF......... .:.. +!F'' -.. ......................
rrtifirate.of f"nnt" hattrr
T IS T ER at the Iildiv.•dualY-Se age Di sal S: m constructed ( ) or Repaired ( �
Ins'natler jT
-t�
at•--•--.. .. .---
j -----
has been inst ed in accordance 5with,.the prove ions of ArticleVol
XI of The State Sanitary Code cribed in the
applicationfor Disposal Works Construction Permit N'o............. '"
= dated ..
THE ISSUANCE OF THIS'CERTIFICATE SHALL NOT BE CONSTRUE® AS A GU .RA TEE THAT THE
SYSTEM WILL FUN ION SA71L
SFACTORY
.+.:J`.} `"4 C i r y '5 4 }v t j cI a�'�.k� ,� �{'R' �:ti sw �• £,n'1-z y,�, r Y {
F,; 1iy�lpATT I L �° r` '.Inspectors � a3
.:'.
5.
THE COMMONWEALTH OF MASSACHUSETTS ~h ,
BOARD OF HEALTH
No....... -•--•-••--• FEE...., ,
trurtion V4T,
Permission is hereby gr'ante ...
to;•Constru t ( e l ( divtdual -Se e Dis o 1 Syst t {orIJ
gat No. Stree ��•
�� t
�€ 4;, as shown on the application for`Disposal Works Construction met Dzted!...
.. 71/ -.--------
B and of'Health
f {
DATE ,/ .------- ---- ----------------------------------------
FORM 1255 HOBBS & WARREN. INC..- PUBLISHERS
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