HomeMy WebLinkAbout0071 CANTERBURY CIRCLE - Health 4^
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NO,M- 4------ Fimn ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH -
jC' ------ . . . ......... OF.........................................................................................
wiration for Uiiipooal Works Tottatrurtion Vantit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System/at:
,7
.................................. ......................................................
Loc. yd;,ation-
or Lot No....._
o. 1—J.
................... . .......................
4�i� ..(!?..;iAdd
Owne .. ......................
....... ......
. ............. ............ ...............I..................
talle Address
le
Type of Building awA91 Size .......Sq. feet
U V
Dwelling No. of Bedrooms._......................................Expansion 4kttic GaMage Grinder
�_l
P4 Other—Type of Building ............................ No. of persons...... Showers (1�� Cafeteria
;14 Other fix,,,tyres ................................................................................................* ....... ---------------*----------*-------
Design Flow...........
W '51-4----------------------gallons per person per day. Total daily flow-____.........? ..-_..._...........gallons..
04 Septic Tank—Liquid capacity
W jov-gallons Length................ Width-_----__-___---. Diameter._....---_-__-_- Depth............_...
Disposal Trench—No...................... Width...._..__. Total Length._.............._... Total leaching area....................sq. f t.
....ye.. o al
Seepage Pit No----- Diameter_ epth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box 44- 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......_-__--___-___-___.
----------------•. . --- ........... --------------------------------------------------------------------
A14-1..................................................................
0 Description of Soil.............................. .............
�4
U .........................................................................................................................................................................................................
------------------------------ --------------------------------------I...................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable.L.............................................................................................
.........................................................................................................................................................................................................
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 'issued by the board of hegalth.,,
Signed.... .... 114X......t•-•Z
Date
ApplicationApproved By....................................... .................................................*........ ........................................
Date
Application Disapproved for the following reasons:.............................................................................I...................................
.................................................................................................I......................................................... ............. -------
7
Date
PermitNo......................................................... Issued...... . .. ... ..........
at
——------------------------------ --------- ------- --- -- - --
No.....
F$$.............................
e
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............. ..........................O F......................................................
Appliratiou for %iposa1 Workii (fouritrurvatt Vrrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System-at: 4`. x t�
Location•Addreys s ° or Lot No. J
... 'r .:.... ..... / ._ ' ..................................t .. ' ..._....,.........
Owner :' yffidards's
.................. ,`t ..............fa..+;.. .. ......y.....X.Y..... ... �p ggf..r .... "`• ... .............................
Installer Address;
Q Type of Building tiE �"t' 'f .,. Size Lot ,` S . feet
Dwelling—No. of Bedrooms...........§ !.............................Expansion Attic ( ) Gatb'age' Grinder ( )
Other—Type TYP of e Building _
G.I � g ------------------••-----••- P .�. , (;'") — Cafeteria ( )
Other fixtures ----•.....................•---•--•••. - - „. f Showers
Design Flow..............`..., ...................._gallons per person per day. Total daily flow......... _____•-_-_--_-__-gallons.
P4 Septic Tank—Liquid capacityt-_'.t,(.`: gallons Length................ Width................ Diameter. ............... Depth...............
xDisposal Trench—No..................... Width..............-.. Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No... F„'._.. Diameter_ .::..; < ,•Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ). Dosing tank ( )
Percolation Test Results'!' Performed by.......................................................................... Date........................................
a
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_..___________--__---.--
fZ.1 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.-__-_____-_-_-.--__-__.
......... rtay ...--•----•---•-•---....---••------------------------•--•--
O Description of Soil................••--•-
U ............................................... •-•--•--------------•--------........---..................._._...--•-----••--•.....:.:.---......--------•-----------•-----...................---------
UW •--••-•-•-•-•--•------------•--••-•-----....---•-••--••-------•-•-•-•--•......................•••-----•-•---••-•-...-••---.... ------------•---•---------------------•-....---•-••..............
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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beers issued by the board of health.
f � I
Signed `..... .. .:,...; f
• D ate+:'
ApplicationApproved By•--••...................•--••......--. ......................................................... ........................................
Date
Application Disapproved for the following reasons:.................................••---•-----•-•••-•••-•••--•---•--•-•-••---•-•-••••............-•-•-•---•.......
............................•------••-------•----------•---....--•-•-----------.......-•-•------------•-.••........----•--••--•---•••-•••--•---••-•-•---•--•---•-•-•-••-•--••-••-•---•--•-•---•.........
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�C
Trrttftratr"of f��rit ttt�trr Y t
THIS'!S TO TIFY,jThat the Individual Sewage Disposal System constructed 00101 or Repaired ( )
a r Installc k�I
r
has been installed in accordance with the provisions of Ar�.icle XI of The State Sanitary G6Ae as described in the
application for Disposal Works Construction Permit No...:.............. �,s '�a dated--------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST UED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
2
DATE ._.1.'.�.g' . Inspector .. !.1�. .. .....................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
s �.�C -,° ...........OF......... .V .-. Z. Ltr:`....................
t� .....
No.,�!`::e... ...... FEE... -- ...............
�It��r�,��ly �tk� (��rn�trttrtt�� �Crrtttttt
Permission is hereby granted.......... . <` G/ '. ..................•-----------............................................
to Construct (A ) or Repair ( ) an Individual.,Sewage Disposal System
at No........ `. ?.........................r; , :,' ,e�� .. ':a �L .;L �` `t:.
Street
as shown on the application for Disposal Works Construction Permit No,; �! .... Dated___-: '� ' .........
PP h
R
yt. -vita A.-__ .........
/• �• d.It
.,DATE_ Board of health
............................. .
FORM 1255, HOBBS & WARREN, INC.. PUBLISHERS - -