HomeMy WebLinkAbout0134 CHASE STREET - Health �s�/Mwrsc 51-. Nyannts
LOCATION - SEGIAGE PERMIT GO•
VILLAGE
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fmST-AL11LER'S MAME A ADDRES
6UILDEIt OR OWNER
1� D-A T E P ERMIT ISSU E a y�
DATE COMPLIAN-CE IS-SUED
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No.._c�. .: t�,►�.. �t'T' FEs......I...�........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD PF HEALTH
040A)..............OF....... .. .... ..c�.. r ----------------------._....-.--
Appliration for Uhipaii it WvrLi Tomitritrtinit Frrutit
Application is hereby made for a Permit to Construct (X or Repair ( ) an Individual Sewage Disposal
System at:
............4:2�7..... ..s-z;.. 1 -�u�..-••---------- ... ...........................................................
LocatiQ�n- ddre ._.......Lot No.
Owner Address
W _ _
d Installer r
Type of BuildinL/... S e lLot _ ._Sq.feet
'� � .....................Ea Expansion Attic Garbage Gander d
Dwelling—No. of Bedrooms____________________ p ( '3 g (`3)
aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Other fixtures ------------- ---------..
Design Flow.............................. ....gallons per person pay day. Total daily qpw--------------- ...........p4lons
WSeptic —mid capacity_ gallons Length-_- . Width.__ ®__ Diameter________________ Depth_ --_ Q.
x Disposa i—No. ............ ..._.. Width......`'.;-...... Total Length__........:_._..... Total leaching area___.3 _�—...sq. ft.
Seepage Pit No—__............... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box Dosing t k ('
'~ Percolation TestResu is Performed by-------- .._... __ ._ . _.jP Date..... .
a Test Pit �To. 1......... - .minutes per inch Depth of Test Pit. ._'L?.._.____ Depth to ground water--------
___
Test Pit.No. 2................minutes per inch Depth of Test Pit....../0...... Depth to ground water...7__..........___.
O .. it`L
Description'of„S'bil-----_�--�'----------------•-`�- ---�-----r-�----��- -------------- ---�---- -------------------------� !'�-------------
x
w
U 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 iT .. , y g g p y 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.
Signed...................................................................................... ................................
Da e
Application Approved By•-•--•--- % �� � ...................
Date
Application Disapproved for the following reasons:................................................................................................................
..•---------•---------------------------------------------•--••----•--•--•-------•------••----- -•-.......--•----•-••-------......------•---•-•----------------•---------------•-••--••....---•-------•-
Date
PermitNo--------------------------------------------------------- Issued.......................................................
Date
S
THE COMMONWEALTH OF MASSACHUSETTS
BOARD PF HEALTH
. ..............oF.......... �.; 1� ......... L
------------------------------------
Appiiratinn for Dispas al Marks Tnnitrurtinn Prrutit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at:
7 .9 Locatign-Itlddrest t or Lot No.
(�r. � 4 .Y_ j..•-� �.
Owner - Address
W
Installer Address ?
.S
U Type of Buildin>'/� Size Lot...� feet
.��.C'_._....._.
q
Dwelling !—No. of Bedrooms....................._-___.•__.--_--___Expansion Attic Garbage Grinder
`L4 Other—Type of Building No. of persons............................ Showers
a YP g ---•--•--•--------•-•---•--- P ( ) — Cafeteria ( )
Other fixtures ..........
----------------------•------------ --•---•-• -----------I,-,,--,-,,,,,,,,-------------- ----------
Design Flow,._ P p y y� C�. Ions.,,
.•---.----•----------------`.���.��_gallons per person `eiz day. Total daily flow---------------�.---:-,=-----•------------__ ++ � �
WSeptic � id capacity..--......gallons Length.... _ Width__' I' . Diameter................ Depth..-`
x Disposal Brach—No.----- ....... Width......1-._2.------ 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._........:�e'�.............................._..:�� _�. Date..... ...1} _•.-_p -.._..-__..
a C_ ,
Test Pit No. I................minutes per inch Depth of Test Pit JJ.(�_....... Depth to ground water-- .-_-_p:.._.__..___-
f=, Test Pit No. 2................minutes per inch Depth of Test Pit....... . ..... Depth to ground water........
07
r . ,.Description of Soil_. 7 Mi. -__-----_ _
V ..................................................
. •------------•---------------------------•-------------------
UW ----3------------------------------------------------------------------
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:TT E1,
p 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.
Signed...................................................................................... ................................
D e
Application Approved BY--•--- --................................
I Date
Application Disapproved for the following reasons:-•-•---•...-•-•-----••••-•-•---------•-••---•--••---•--•-----•--•-••----•---•-••---•-••.........................
-------------------••.......---•-...._---•---•---------------•------•------------•-•----------•-•-•------
Date
Id Permit No......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS.
BOARD OF HEALTH
OF...................:................................................................
(Intifiratr of GautpliFanre
THIS IS TO CERTIF Th h I dividual Sewage Disposal System constructed ( ) or Repaired ( )
by. ".,.�' --•---- ---------------•--•-------------••--------y---•-••-•-•-•-•------•------------------........---•••-------•••----••---•-•---•------
AP In tall
at............................. .................' -------/.#
........................................................
has been installed in:;accordance with the provisions of TITLL of The State Sanitary Code as,described in the
application for Disposal Works Construction Permit ivo...._.___._7_____4� ............... ted-.----_fl...._.....__.___......._........
THE ISSIJAN E THIS CERTIFICATE SHALL NOT BE CONSTR AS ARANTEE THAT THE
SYSTEM WILL NOTION SATISFACTORY.
DATE....... b �! Inspector.... --- ---•--•-•---••--------•----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..............OF.....................................................................................
No._.......:.:.�'........ FEE... ..............
Disposal Works �nng Wn rrntit
. yam,
Permission�isreby granted••••-- o...•••..r/'&..._.. ; --------•-----•-•--•.........................•••------••••--•....------......
to Construct Repair ( an d' ual Sewage Dispos ystem
at No. r
....- �^.-- ................... ....... --•--•••--•.....-------•--•--•----•----...--•---•.................
Street
as shown on the application for Disposal Works Construction Per it No..................... Dated..........................................
oar'�d of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
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