HomeMy WebLinkAbout0048 SNOW CREEK DRIVE - Health � � S� ciwk 'Dr
LOCAT N / 5EW�,GE PERMIT UO.
It Az-41 j- _ _ a�
VILLAGE . - - s — —
IMS-T41,LEV3 5 ME P. ADDRESS
BUILDE S DDRESS
DINTE PERtAlT ISSUED .— =��=7-S
D b.TE COMPLI & aCE ISSUED :
4
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... ..�........
THE COMMONWEALTH OR MASSACHUSETTS
BOARD F HEALTH
or--�f�'j,( L........OF...... .e .. ... .. .......... . ............
t.nht5 Appliration for Disposal Works Tomitrurtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Syst at:
Locatio - dress
-- --7
! o.
W Owner Address
-----. ----- ................y----- f ------------
nstaller Address
U Type of Buildin Size Lot.- _ �Sq. feet
a Dwelling—No. of Bedrooms_______________ ��______-_Expansion Attic ( ) G rbage Grinder ( )
aOther—Type of Building ____________________________ No. of )) rsons............................ Showers ( ) — Cafeteria ( )
Other fixtures _______________________________ __ $_
--•--------•-••-••--------------------------------------------------•---•------------
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 I Ching are- ----------------sq. ft.
Z Other Distribution box ( ) Dosing tank ({� ) �. ,
aPercolation Test Results Performed by ���----------------•-------- Date.
Test Pit No. 1................minutes per inch Depth oV'Test Pit.................... Depth to ground water---------------------_
�Lq Vest Pit No. 2................minutes per inch Depth of Test Pit..................;_ Depth to ground water-----_------------------
a .............---••..... -----W.:V -• --------- ---•-- -
O
Description of Soil. . ------------------------------------------------------------
V -------------------------------------------------------------------------------•------------------- ---•----------••-------------------------•--------------------•-----------------------.--•--------
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 Article YI of the State Sanitary Code—The n ersigned further agrees not to place the system in
operation until a Certificate of Complianc s been issued by e�Drdof lth
. .. ......5
SignIj
ed
Application Approved BY --- ----•-•------- ------
Date
Application Disapproved for the following reasons:--------•--- ................1-••-----------------------------------------------------------------------------
D.te .
x
Permit No. Issued..--------- -----.....
D e
.v
-cum . ..�..��.�- � ----- ...� -__ �yu.�.�.._---- ��.�..�._____�._�►.�..�_u.. �__. .._._�_._.�__�_-__-__-_�_�____-�
No.._ --• •--- FlzE. .....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD GF HEALTH
m,
Appli.ration for deposal Works Tomitrurtiun Prrmit �
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Syst at: I # �"
4 ram" °" •�
e.
{ L�ocahon dres s N
W Owner Address,
._....ae ...... .._... ---------------•---.........- L7 -----•-----__-______-------
Installer ° Address Q
Q Type of Building Size Lot_._ _ __ _ Sq. feet
Dwelling—No. of Bedrooms_______________ .......................Expansion Attic ( ) Garbage Grinder ( )
p, Other—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. ............4....... Width_.____..___._.._.___ Total Length.................... Total leaching area-____--_____.-_--___sq. ft.
3 Seepage Pit No..................... Diameter.................... Depth below inlet..................... Total leaching�area ................sq. ft.
Other Distribution box ( ) Dosing tank ( ) _ , �i �' w
a 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..............:_______-.
o ............. ---•-- .. =-----------------------•--•----------------......-----
00,
Description of Soil------ --------------------r- °' . ---- � -----------------------------------------------------------
W ----------------------------------------------
....'
UNature of Repairs or Alterations—Answer when applicable-----------------------------------____________________________________________________________.
t
Agreement:
The undersigned agrees to install the aforedescribed Individual S wage 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 Compliancesbeen issued by the board of) ealthr
Signed '� '� *s. f :' tt� y�" '' *e -•-•--• ...............................
In
Application Approved BY - --•----•---- = .. -----
ate-
Application Disapproved for the following reasons:�........................__... ._-............................................------ _•..............
f
a
Date
.� Permit No......................................................... Issued........................................................
j Date I
e
THE COMMONWEALTH OF MASSACHUSETTS
BOARD TH
I A.............0F.......... �Z....
Trrtif irate of Tome ianrr
THIS TO ERTI • That the Indivl ewage Disposal System constructed ( ) or Repaired ( )
by ; '' ------------•---------------••-•----••---•----•-
----
{ nstaller
at l _.
0U.' .1e rtt
has been installed in accordance with the provisions of Article.XI of The State Sanitary Code as de cribed in the
application for Disposal Works Construction Permit No.__._.__._� ' __. `_____________ dated_.+ __ _: __.�-
o
THE ISSUANCE OF THIS CERTIFICATE SHALL`NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE .....-- Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD PF HEALTH
� m
If
....- .................
No..--___... - FEE
Dhipog yr Tat rurtion rrmi# _.. r , .
to ConsPermisstonf is ereby or Re r nted 'an Individual¢ ------- `L =-- -••-- --------------- --- -...................................•p - ) age DIs osal Sy #ems
at No. :.� ¢:_. _- � .. * "' -- -_ - - - ->----- ------ -•_.- -----
str
as shown onTO
/thea licatio/n5,
osal Works Construction it No -_. __!' ated__. __ _________
• -- ---------------
DATE.._� Board of Health
FORM 1255 WAR BLISHERS