HomeMy WebLinkAbout0033 BREAKWATER SHORES DR - Health 33 Breakwater Shores'Drive Sewer Acct# 3260
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IMST-A Ll R'S N.AOE A ADDRESS
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DATE PERMIT ISSUED
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DATE C 0 M P L I A N C E ISSUED � �
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No.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARDLAOF HEALTH
...OF......
Amifiration. for Uhipasal Works Totwundion ramit
Application is hereby made for a Permit to Construct or Repair X an Individual Sewage Disposal
System
... ... .. ... ... .... ... .................................................................................................
System
Location-Address t
.
-----------------------------------------
Owner Address
....... --------- -444S----------------------------------------------
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder
Other—Type of Building ............................ No. of persons..................... Showers ( ) — Cafeteria
Otherfixtures ......................................................................................................................................................
Design Flow......o.....................................gallons per person per day. Total daily flow............................................gallons.
1:4 Septic Tank—, Liquid*capacity............gallons Length________________ Width_._.-...-..._... Diameter...-_._._____-_. Depth................
Disposal Trench—No_ ____________________ Width______.____._.._.___ Total Length-___.._...._________ Total leaching area....................sq. f t.
Seepage Pit No--------------------- Diameter____.-._....-.__._._ 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..-_-..----___.__.._.---
�Xq Test Pit No. 2................minutes per inch Depth of Test Pit---.._.__.__.___.__. Depth to ground water...-_------___..__.-----
9 .... --------4-
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0 Description of Soil...............
W
M --------------------*------ ------------------------- --------**-------------------------------------------------*-----------------------------------------------*-------------------
Z. ............................................................................................................................___r. ..................................................................
U Nature of Repairs or Alterations—Answer when applicable.--__._.--.-. I----------------------------------------------------------------------------
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITS 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate o;fCornpliance has n issued by the bWrd of,b�ealth.
Si . . ......... --- )D
Application Approved By-..... . .. .. ..... . ......................... .....7�7:7.. -----------
Date
Application Disapproved for the following reasons:..................... .........................................................................................
...........................................................................................................................................................................................................
V Date
PermitNo........................................................ IssuedL.... :'_ ._.........--------------
Date
f J. �
No.......
THE COMMONWEALTH OF MASSACHUSETTS
BOAR,®,-.._OE HEALTH
1..i .... .... !....OF...... 1 1. f I _� /r1 .. f t`
Applirttiinn for Disposal Works Tonstrur#inn runtit
wx Application is hereby made for a Permit to Construct ( ) or Repair (>- .) an Individual Sewage Disposal
System at
M.• ` ..
Loca ion Address •or Lot No.
.....-LL-} ---•,•-;---......--•---•--•-•-•-------. _ . ................. 7 f
...
tt y - Owner, � f Address
--------------------- ----_ . . •... .-•--- ---
Ins tiller r Address
Type of Building Size Lot............................Sq. feet
�-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ... No. of persons............................ Showers
a YP g -------------•-•--.._---• P ( ) — Cafeteria ( )
P4Other fixtures ..------•-----------------------------------•--.....------•••-•-••••-••---•--•--•••-•----._...-•••-------•-----•---..._•-------•....------•-•....----
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank 4t:—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—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 ( )
a -Percolation Test Results Performed by.......................................................................... Date....................................= ..
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
---------------------------------------------•----•-•-•-------....-•-•---...-------•--.........................................................
f .
Description of Soil _ . ;......................•--•--••----••-•••......----••_-•---
W
U Nature of Repairs or Alterations—Answer when applicable. A-----
--- -----------------------------------------
.-------
_---------------------
_ 1
•--------------•--........--•--=-••-----•----•---•-•-----...--••-------.................--•--•-----------•---•-----•----•-----•--......--•-------•-•---•--•--•--•-••••••--••••-----
Agreement': `y
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of- 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 board of health. }
+ r
Sil. • y Da,
Application Approved By-- .. .. .. �! [.••'"1` -
D ate
Application Disapproved for the following reasons:.................... ---------•----•-•••-------•-•--••-•-•-----•-•--•-•-•------•--•-••--•-•-••----•••-------
. ............................................................................................................
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...........................................
.............................................
Date
Permit No. IssuecL _.
..•� ................•------..__..._..----....._........_.... •,;----- ------••........................
Date
THE COMMONWEALTH OF MASSACHUSETT!
BOARD OF HEALTH :
.............y `:.'�. :....OF....:� ...............................................................
Vurrtifiratr of ToutpliFanrr
THIS IS TO CERTIFY; That the Individual Sewage Disposal System constructed ( ) or Repaired
.
�� .r..f i i j............................................�~ .....:.:`..............•---•----..............--•--------•-•-•-•---•---•--•-----------
by................... ....--- --...... -.� Installer
1
............................._..--•---•-------....--•---.....-•-••----•--••----........ ......--- .... .
has been installed in accordance with the provisions of$ r of The State Sanitary Code as described in the
application for Disposal Works Construction Permit �T __._._ • .___...._._. da.ted__... -'`�.7 .................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE.CONSTRUE® AS A GJJARANTEE TA IT THE
SYSTEM WILL FUNCTION SATTIS_FeACTORY.
s.. �,
DATE................ ......- •------•-----...J
........................... Inspector............. ---......---•------•--- --•• - ................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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No.......... ..... FEE......:...............
Disposal Vorks Tuoustrudiath,Wratit
Permission is hereby granted .......................................... ... ----------•---•-----•---------•••••--•......._••••••......
to Construct, ( ) or Repair ( ) an Individual Sewage Disposal System
street /
as shown on the application for Disposal Works Construction Pe No /_.11/_r. _._ _ Dated ".��
A.__._ ` ''_..t__��...............
t..(,,,_•-•___ ------fir'....
--e..-, -•-------.-•.__.._._
Board of Health
DATE.....7 7-� -----•-•-------------••---•--......_....
FORM 1255 HOSES & WARREN, INC.. PUBLISHERS