HomeMy WebLinkAbout0983 SHOOTFLYING HILL RD - Health (2) 9%3 ShmlAa i n� t +p Rd, (rn�
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
Tow.n....................OF........... rn.at able
Appliration for Dispoti al Works Cnow3trurtiun Vanat
Application is hereby made for a Permit to Construct ( ) or Repair (Y4 an Individual Sewage Disposal
System at:
83..3.haatLf..jy.jMZ...k� ��... oaa.Centerv_11lea--------------------------------------------------------------------------------------------
}}QLocation-Address or Lot No.
.._._V: ' .........1knIgn ................................................. ........•----•---------------------•---------•---------------•------..............................
Owner Address
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling-X No. of Bedrooms........... _..._Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) Cafeteria.( )
Q' 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 Test Pit.................... Depth to ground water-.___-_____-_-__-____-_.
Gz, Test Pit No. 2................minutes per inch . Depth of Test Pit.................... Depth to ground water-___-______-_____--_-.
O Description of Soil........... an __& _CiX''dVel
x -------------------------•-------•------------------------------------------------------------------------------•----•--•-----
V ---••-••---••-•-•-•----••-•-=-•••--•-•----•--•------•-------•-----•--•-•-....•••-•-------------------------•-----•-•-----------•------••--••-•--•---•••-••-••----•-•-•-•••-•------------•-•--•----•-----
W
UNature of Repairs or Alterations—Answer when applicable--_1-�1000__gallon le_ac h--.pit,_.._--____•.............____•__-__
-••-•- •---• •---------••----••------•...••-•--•-•-•-•-•--•-•--•--••----•-------•-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of i i T L L 5 of the State Sanitary Code— The and rsigned further agrees not to place the system in
operation until a Certificate of Compliance has be issued by he ar ofilealth.
Signe ---- --------
Date
Application Approved By............. -- -• •. .............................-----------
Date
Application Disapproved for the following reasons--------=------•--...-----:..---------------------------------•-----------------•--------------•-----.....•-•---
---•-•--•-••--••••--------••-••-•----•••---•-••--•-------••••--•---------------••----••-----•----•-••-•-------------•---•----•--••-•------•••---•-•----•---•---•-------•----•-----------•-•---•••-------
rt
Date
Permit No........$' 7 � �1��---------------- Issued----------------------------------•----.........--....
Date
Q
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Appliratinn for Dispniial Workstumitritrtion ami#
Application is hereby made for a Permit to Construct ( ) or Repair (...,.) an Individual Sewage Disposal
System at: 4-4
Loeat.on-Address or Lot No
:C=......._.......................................................................... ..........--...................................................................................... .
�+ rt Owner Address
�i'... ----•-----•-••--••----••------ ............................. ............ ........ ......................................................._.....
Installer 1 „ Address
UType of Building Size Lot............................Sq. feet
Dwellingw. No. of Bedrooms----•__-..-Z--------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons........................--.. Showers ( ) — Cafeteria ( )
a .
Other fixtures ----------------•------------- ------------••••••-•-----•---•------•....---•---•----•--•••••----•----=•••••--••-••-------•---•--•--••-----.
Design Flow................
w -._........................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 imlet......-:............ 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........................
tz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..-. --.-------.--.---.
Pd
O Description of Soil..----- - '- ,`*• St<,f t;=r4- - - -- ................. - ...
U -----•-•---•----•-----•••••-•-••••-•••......................•----•----............------------------•------------•--------••---......-----------------.......----.-----.........-••------•-••----------
w
----------------------------------- -- ---- ---- ----------------------------
U Nature of Repairs or Alterations—Answer when applicable..:L�tj�� ..........................
--------------------------------•--------------------------•••--------•---••---------------.......••-•-.....----•-----•-----••--•----•--•---••-••---••-•••-----------•--•-------------•------------•--.
Agreement: "1
The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with
the provisions of i i_:E 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.
r
Signed E" r�"
�/ t�rc. ------- --------•--
�*c 9�''�'a Date�
Application Approved By.......... _.__ ..!_._:._
-. �
Application Disapproved-for the ollowing reasons; Date
..-•----------------------------------------------------•----•---•-•---••----------.........--- ---•--------•----------------------••--------•----•-••----•••-•••-•---•-------•---- •----...--•---
Date
PermitNo.--- �i A � -fir................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
O F...'r'..:: ,. .......................
Tnrtifiratr of TautpliFanrr
THIS IS TO CERTIFY,That the Individual Sewage Disposal System constructed ( ) or Repaired ( }
Installer
_ . ..�__..,. --
has been installed in accordance with the provisions of T i TIE j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit dated------------------_----.-.---................. .
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE---•-----------------7-:::fr-... .......................... Inspector--- .....................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......�.n:..a...........................OF..... ....................................................
FEE........................
�iu��a��tl nrku ��an��rttriinn rruti�
Permission is hereby granted....... ,.._�.q.__ _r;;_ .__......._
to Construct ( ) or Repair,,( ) an Individual Sewage Disposal System
i. I 7?rt F.CItr �; 111
u 1�0. '._•.) = 1.: �............ .......................L ......----••--------•-------•-•----•-••---•----•......--•-----•--•-•-----•----.
Street
as shown on the application for Disposal Works Construction Permit 17"
._ Dated..........................................---- -----•--- - ------------------•-----------------••--------•----
DATE---------- ^-- �/r• j ......................... d
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS