HomeMy WebLinkAbout0817 SHOOTFLYING HILL RD - Health (2) 817 3641til I II , (Enk.
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N.......ll.. . . 1 � L l Fss....�'Z.l ..
THE COMMONWEALTH OF MASSACHUSETTS
I
BOARD OF HEALTH
t, .
A#p iratiun for Dispasal.19arks Tonstrudiott ramit.
Application is hereby made for a Permit to Construct ( ) or Repair ( inn Individual Sewage Disposal
System at:
--•---.. .__. .�: fi. 't: ...:vl.-I�............. ......... G 'v 'z a�� --.......-•-----•••---- -.........
Location-Address or Lot No.
.............. .:..a, :�: ............. .................... -------------- .......--.......................
Owner Address
... ......................... � � ...........................................
------------- -
Installer Address
Type of Building. Size'Lot............................Sq. feet
U Dwelling—No. of Bedrooms.........._ Expansion Attic ( ) Garbage Grinder ( )...--••-------------•---
Other—Type of Building .............. No. of ersons................._.......... Showers
� YP g --._.....-•--- P ( ) — Cafeteria ( )
Otherfi s •••---•••.................................•-...--••--•.•-•-••...........---•••--•-••--••----.............•---••-•----.........-•---••-•-••......---••-
WW Design Flow........ .................................gallons per person per day. Total daily flow.....:.....��_..�.................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................. Diameter................ Depth................
Disposal Trench—No..................... Width.._............... Total Length................... Total leaching area....................sq. ft.
x ..
Seepage Pit No......1............. Diameter.__.' ......... Depth below inlet_..-,g:�......... Total leaching area................:.sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by----••------------------••-•.............. = ..... Date----...................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water....................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground "water............_...........
a ....................••••.........• •--- -------......................................... .......................................•..............
0 Description of Soil.........................................................................................................................................................................
....................•••--.... -•••-••-•--------•--••••••----••••-•--••-•••--••-----...........•••-•-•--••-•-•-••-------•--•--•------...---•--•-•-••••--•••-••--•.....................•---...--••--.....
U Nature of Repairs or Alterations—Answer when applicable...._4=•"-------0 :-----:-0-V-44T--- --------(111a:
. :.... oar.------... . .. �---.....-..: -...................................................................•-----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of L ITL% 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 b�11
S><gned.--------•- tom' D
_._.
ati
Application Approved By............:....� _. .. ..-. ..
Date
Application Disapproved for the following reasons:............................:..............-...................................................................
_
.............••-......................................................................................._.........................--•--............................................ ...........
Date
Permit No..------9
- ---V.1---------------•---•--.... Issued.....................................................-- /
Date
No..... yf 2 y l FEs . .._. ._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
1 c✓v.1 OF I��. ......................................-Q-Vr h � '
.... _...............................
Appliratinn for Disposal Works Tonstrur#inn rrrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( U)*a`"n Individual Sewage Disposal
System at:
.....--•---...___--__................. ............ ---•--......._..... .............•.........__.....---- -• ....................._...--...---...................
Location.Address or Lot No.
Owner Address
C_ -. L- O yv o .5,e'4�.r `ram M, y r-
.............. ---••.....•••.......-•-----••---......--•-•••.................••-•r- •• ..............................................
Installer Address
QQ7ii Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.......1...............................Expansion Attic ( ) Garbage Grinder1.4
( )
p.t Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
04 Other fixtures ...............••---•--•-•----.................
W Design Flow.......:2..........................................................gallons per person per day. Total daily flow......... 7-4'_?.................gallons.
WSeptic Tank—Liquid'capacity..._........gallons Length................ Width.,............... Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................sq. ft.
c
3 Seepage Pit No......I............. Diameter....a...___.__..... Depth below inlet.._/ .(._........ Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed bY.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
L� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
pG --------------
•------------------
.......... -----------
-.---.................._.._.........----------•------•-----------------
...............
0 Description of Soil...--•..........................................•-•--•--•--•-•--•--...........--------------•----•------•-----•-•----•-•................---.........-•-•-•........•..•••
....-•---•---------------------------•----------•-------------•--....-----•--------•----•--.............------••---------------......••--------------•------•------•--------------•-•-•........ --••-•l
U Nature of Repairs or Alterations—Answer when applicable.......41V....... +' _._.._.4,u�...00F:T......t,,_
......a T/r... ._........-.�1<r-- �-----�'r �„� Dar:j .
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL 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 issued by the board of health,-
Signed...... -- ._.... ----.. -- . �_ ....................... ................................
Date
Application Approved BY..........................- ....---��__ _.=.. r-�-
............................ --•--...............Date ....,...._.
Application Disapproved for the following reasons:..............................................................................................................
-
................................................................••---•---........•-••••••••••----•---...............••.......-•---------•---•••••----••••..._...............•••--•... .•---.......--
Date
f
PermitNo......... ....... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....' .O.k�^�.....OF.T. c,y v S t. .....................................
(9rrttif irate of Toutplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) `or Repaired
by ......... ............................................................
Installer
at..........�? .5...o T' ��. i t l-ry_.... pi� l
.e —"
has been installed in accordance with the provisions of TITLP, 5 of The State Sanitary Code.,as described in the
application for Disposal Works Construction Permit.No.........R•Ss_-__4 ./-........... dated................................................
�-- - THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...................... 1 I - r/�..................................... Inspector............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........���;!i..O....- OF...���r..,._.r t,�_.sT��l-ra...........................
No......................... FEE........................
Disposal Works Tonutrurtinn "rrntit
Permission Is hereby granted.. ;I` -r!'r(/� .T: OT?
to Construct ( ) or Repair ( t)�a._n_ Individual Sewage Disposal System
C '� t ! n n'7""� L ,,,E h E-1 t � ........-•---..... .,e.v�-�r
Street
as shown on the application for Disposal Works Construction Permit No.. k .yl.___ Dated..........................................
...= ----------------------•-•----------•----..-----------•-----
' Board of Health
DATE ---------•...........................••-•---••------•••••.