HomeMy WebLinkAbout0067 BREAKWATER SHORES DR - Health I ,67f3reakwater Shores Drive` Sewer Acct#3304
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CATION :
' SEWW E PERMIT UO.
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VILLAGE
It�lSTQLLERS 1Jl�,P/lE � ADDRESS
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BUILDERS Q I MF- &DDRE SS
DATE PERMIT ISSUED -
D A.TE COMPLI &N►CE ISSUED : a az !- .
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
. �J .............OF... ...t._.................------....................----•-
.� Iirtttiutt -fur Utsvuiitti Works Tiltuarar it
/tilau rrni
Application is hereby made for a Permit to Construct ( ) or Repair ( ) a' n Individual Sewage Disposal
S stqm at:
Loention-A dress or Lot No.
� wner.. .......... .......�� . -��__�._..' _ Ill.,�---._..._._.. .........
..................................
Address
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No, of persons..._____---______-_---__---_ Showers ( ) — Cafeteria ( )
a Other fixtures ----- ------------------------------------------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
0i Septic Tank—Liquid capacity.---- ------gallons Length---------------- Width................ Diameter_-.-....-..----_ Depth________.__...
xDisposal 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 ( )
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........................
P4 ----------•-- ------------------------------•----------•-----•------------•----------•-•---------------•-----•------••------------------•----------------_-----
ODescription of Soil.........---------------------------------------------------------------------------------------------------------------------------------------- ----------------------
W ------------------------------------------------------------------------------- ---—--- ------------ ----- -
------- --- ---
U Natu of Repairs terations—Answer when applicable._..______ _ __ _ __ _ ______ __ _ -__---_--_ ----...__ __..__._._...-..
-�---1- --- - - - -- -------- ------------------------------------------ (J c
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be ssued by the board of he -
�s
Date
ApplicationApproved By----------•------------...........................................................................
Date
Application Disapproved for the following reasons----------------------------------------------------------------------------------------------•-----------------
•-----•-----------------•-------------------------------------------•-•--••--------•--•------------------•----••--•-----••--------•-- ------------------------------------•--•----------------------•---
Da
Permit No.-....{ �� Issued--/1.--- .
Date
ao
No........•-----u3-�------- FEE..........:...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD R F HEALTH
.. .........OF.... ... .......
Apphrtt#iun -fur Uiopooal Workii Tono#rur#ion Vanti#
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
Syst at:
.....................sue> .......0._._....� d._._/__t.`�� ......... ...... A
(�/�✓ � /Location-Address or Lot No.
W ner Address
t
Installer Address
UType of Building Size Lot............................Sq. feet
�-, Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures -------------------------------------------------------•---------•----------------
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 "Pest Pit.................... Depth to ground water___.---._.._.--.-_..___.
�14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-..-..-..--.--..---_.._.
Ix -------------------------- -----------------------•----•--•"-------•-----------.._....................-----.....•------••-•--------•--•--••-----•--•------...
ODescription of Soil---------- -------------------------"----"---------•"--"-----------"--------------- ----------------------------------------------....--------------------------------
x
x r f O Q Y7)- -----
U Natu of Pepairs erattons—Answer when applicable.-.. .. ___tea _. .___../................/f._....... _..._..___.....
��`-'r" ------------------------------------------------------------------------------------_--_-..-.-.----/----------------------------
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 be ssued b the board of he
Signed._ , r - ... -----------------------
Date.-
ApplicationApproved By----------------------.....................................................-------_------------
Date
Application Disapproved for the following reasons:------.--•----"................•-•---•----•---...----....--------------.........-----------....--•••-----•--•"
----------------------••----..._........---•-•--...-----------•--•------------------•----••-----•-••••--•........-•-••--•--------------••-----------•-----------•--•-•-----------------•••----...........
Date
PermitNo. --3-3-""-----------------"------......--".. Issued...............------ -----"---"------"-"-------"------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................. ` �c cc ....oF.........��'. �L� Tit he e
... ........ .......................................................
larr#ifira#r of fI'amplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
b ............... ..r4 5.....-•-------<<................................................s'�°�Ve s
.-•---------------•---•-•-•-••••-••------••-•--•---•-------------------•-••............--•••-••---
Installer
at ... ---------------••-
has been installed in accordance with the provisions of :Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No----------- .j_3-------------------- dated........ �_�_;�-__�_�.............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
� c
DATE........... S... Inspector GG l/ ----•------•------•----•----------•------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................Tl:.u' `'....OF........ ftSrl94. .
No...............3..._.. FEE - "
Dinpoottl urk� dun #rtir#iottirrini#
Permission is hereby granted--------- U ... �✓�I`�1 _K- s�TF/c `'=� s = ....... =..=f S
to Construct (,/) or Repair ( ) an Individual Sewage Disposal System
at No.--------?v•---------fh................................................A-/l ( /9 TE/i ._St cAe s /� ;�p����/S .
........ ......-- --•-- ------•-----........-----...------------.....------•--...--•--•---••-.--
Street
as shown on the application for Disposal Works Construction Permit No-----��.�__- ----- Dated........_��_.�� 7 S^
J Ioard of Heal-
DATE............. s -- ....................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS