HomeMy WebLinkAbout0780 SOUTH MAIN STREET - Health (2) �9S Doi
No....-3 SO Fizs..... .. °....:n
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................................._.......OF.......................................--------................------.....................
Appiiration for 11ispos al Works Tons rurtion Frrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
S stein at
D r �1�r/ r CC 4VTJ- I/f J,j �"
.. .. ....._ ........................................................................... .....-•-•-------.....--••-•-•-•-•---•----•--•••-•••-•--•--••--•-••-•-.......•--•..................
0tion�-AddLrIeJ Lor oca s
__ -- .... No.
•-•••--•---------------
ownfr
Address
./ ���T"-+
. ..
... •-•-•--••--••--•----•-•--/-----------••--•-------•-•-••-•--•---•.........Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms----.......3....:......................Expansion Attic ( ) Garbage Grinder ( )
p-, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ---------------------------------
W Design Flow. ........S_�._.-1gg -gallons per person per day. Total daily flow................ .3 ................gallons.
W' Septic Tank—Liquid capacity,- . ..gallons Length................ Width................ Diameter--.--.-.-.--.--. Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No........�........ Diameter....4LYI." Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ()�,) Dosing tank ( )
PercolationTest Results Performed by.......................................................................... Date........................................
14 Test Pit No. 1................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........................
0 Description of Soil...................................
U ---.-----•----------------------------------e---- h ._...........----••----------•----.........-•-----------•--•----•-•-----•--------------...•---......._.......-------------•-------..-•--
- --- -- ---------------- ----------
W .--•--•-•----------------------------------------------•-----------•--------------•-----------------------------------------•-----•--•--------------------•-----...---•-•......---•-••--•••......•----
UNature 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'MTLE 5 of the State Sanitary Code— The undersigned further agrees not to place t/hem in
operation until a Certificate of Compliance has been issued by the board of healt
Signed_.. .................... .....
•
Application Approved BY - ` •................................. -----------------••--------••-•.........
r-----------
Date
Application Disapproved for the f of ing reasons---------.......-------..................
-.....................................................---•------•---------
--------------------------------------------------o----a-------------------------------------------..._.._...-----...._..---------...._..._..�:-----7�------------------.._.-..------------
Date
Permit No......2.14 ..................................... Issued Issued_--•--------........... ---•----- ------
Date
No.._ ?.......... Flms.... ..
08
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.......................................
.
App irtatiou for Disposal Works Tonstrnrtiun rrmi#
\.,Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage l? ,posal
S stem at:
ocation-Address Logo
• e . ; "a
.......................... ..... �..... '. ... - .. ...
Owner Address
,-7 ..------. -7---------------------- - �._....... :.ddre s --------•-•-
� ,� Installer '. As
d Type of Building Size-.Lot............................Sq. feet
U Dwelling No. of Bedrooms...«........ _ .Ex anion Attic AGarba e Grinder
a "Other—Type of Building ............................ No. of persons............................ .Showers� ) — Cafeteria ( )
Otherfixtures ----------------•-------------------------------------`------------------------------------------......= ...........................................
Design Flow.._�........6. ... a --.gallons per person per day. Total daily flow.....- }_.x Q.................
W .. ... f����g P P P Y• Y 4 - gallons.
WSeptic Tank—Liquid capacity5 gallons Length................ Width. Diameter Depth................
x Disposal`"Trench No Width__ Total Length._.__.._ Total%'leaching`area...................sq. ft.
3 Seepage"Pit No..........4--------- Diameter... Depth below inlet.................... Total leaching area............._....sq. ft.
Z Other Distribution box O L Dosing tank ( )
Percolation Test Results Performed`,'bY.......................................................................... Date........................................
aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2....,..�w.......minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ---•--. -•--••-•-•••--•-••---••---•...................................•......-------•-..............................................................
D Description of Soil................... r
"; <.; ,
W __..._.... . . 7.. ..... .. .f• ......----•-•••--••----•-----------------•-••--------•--•-•-•-----•--•--..............•-•------•••---....------------
----------------- ---•-----•------------------------------------------------------ ---•----------•------•-----••--•--•-•-••----•••--•--------------•••--•-•--•-•.......------------•-•-•.............--
V 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'ITL_ 5;ot the,State Sanitary Code— The undersigned further agrees not to place the syslem in
operation until a Certificate of Compliance has been issued by the board of healt
�.. .
Signed .. ...... ". .. ... .... .............--
Application A roved B
( 1/ /+ir✓6 / ate
Date
Application Disapproved for the f 1h wing reasons:-------•-•••.{-------••---••--•----••---•-----------------•------•-•-•----•••----------•-•---•-•-.....----•---
...................•......••--------•--•----------...--•--•------•-----•---•----------.......•-------•-•-----------------------•-••-•-•---•-----•-•-•--•-•------•--------•---••--••----•--•-----•------
Date
Permit No...... ................................ Issued- ................... -
,l.P ate
K d;'
THE COMMONWEALTH OF,,:MASSACHUSETTS
BOARD OF HEALTH
OF.......... A.4�5;'h I t.r....•........::. ....:.. ................... ................. ...............
(9rdifiratr of ToutpliFanrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (V)
bY-----------------------�Tl���.�...-----.....------. '�!........................�
t
Iat
nstall
............................•......---....._.......••------------------------..........---•---•--•••.
has been installed in accordance,,with the provisions of TIT LF,' 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No: ""{_ ................... dated...... _ .` _'_ ..................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. v;
DATE...... a ` =<" Y * ` .° Inspector.
THE°COMMONWEALTH OF MASSACHUSETTS
BOARD OF`"'HEALTH
...0 F................... ........................_............_.........................
No._.......�.'�....G..... FEE........................
Disposal Works Tilustrurtiou Upamit
r _ t r r"?k�z CS ,
Permission is hereby granted......✓ e5t1C -_t: ..............
..•----
to Construct ( ) or Repair ()() an Individual Sewage Disposal. System
at No '
�....•r -..i e
Street r
as shown on,the application-for Disposal Works Construction"Permit No. _:�.Al..6... Dated..._...................................
.... ...... ---t . --- • ------------------•-
E Board of Health
DATE.......... '__ "`.` ..•.--......
FORM 1255 HOBBS & WARREN.' INC.. PUBLISHERS
Y k.