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Home My WebLink About0012 BISHOPS TERRACE - Health (2) �.�-� - aim ,r� �� A a Y i S THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .........OF.................................................................. Applirativrt fvr 43ispotual Workii Toustrurthin Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ............L.�T...:.... ��........��.. ................i............. ......;11...�,v�/S Location Add ss — or Lot No. ................... .lf.,,........ �9.. .. ..,.............................. ...I...............`...��........10:...'!&/. ._.._..../y !�.�..``!s w �� .s ... Z� y�� Address ................. /v .Instal4ler ,z......................... ........................................... Address.......... ............ ..............-- UType of Building Size Lot.............................Sq. feet a. Dwelling—No. of Bedrooms..... .................................Expansion Attic ( ) Garbage Grinder ( ) '04 4 Other—T e of Building ..... No. of persons.....________________________ Showers — Cafeteria a Other fixtures ...................................-.:. W Design Flow...... ....15lf).....................gallons per person per day. Total daily flow-------- o .......................--gallons. WSeptic Tank—Liquid ca acity-_lU� allons Length................ Width---------------- Diameter................ Depth................. x Disposal Trench—No. > �(�_�_�_ idth.................... 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 ( ) W Percolation Test Results Performed by............................................................................. Date........................................ Test Pit No. 1................ininutes per inch Depth of Test Pit-------:------------ Depth to ground water...___-________._--.--. t=, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ O Description of Soil------------ ------------------------ ................��lcG?�------------�}�f7- ------------------------------------------..__---.--...----_---------•---•-- W U Nature of Repairs or Alterations—Answer when applicable--._-------------------------------------------------•---------_-._-.,..-___-_-_-_-------------- ---•-----------------•----------•••••-------•----•-•--•-•-------•••-••-•----••----••--•--•----------•-•••---•-------------------------------••-----------••----•-•---•...--•--- ........................ Agreement: The undersigned agrees to install the aforedescri ed 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 been.:•iss tied JJlIby t of heal . SignedJ.�"'°'� ...�.. . .. . ... ...................... ................................ p �� Date Application Approved By........... ... ?fit-f'-___..__`......... 'l.� .. Date Application Disapproved for the following reasons------------------------------- ----- .......................................................... ---------------------------•-•----------------•-•-•------------------------------------------------•------------------...................... 22 e� Date Permit No. �l v....-.... Issued.. / d 7 � Date No._... THE COr,4MONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............. ........ .............'OF........................... Applirativit for Disposal 18ink,15 11inuitrurtivit Putnit Application is.hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: J cis .............4.0.2 ....... ..................................................... ................... ......................................................................... Location-AdoAss or "U.2j!�...........Z2Z .................... �LX.................................... ............................................X�ir............................................... Owner Address ...................r .......44 ............................................. .......................................... ..........*........... ------------- Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.............................................Expansion Attic Garbage Grinder a Other—Type of Building ...... ..................... No. of persons............................ Showers Cafeteria Other fixtures -------------- ...................... ................................................................ ------------------- Design, ......Flow....... . ... ................ 7, .�, Vga Ions per person per day. Total daily flow......_............__...._:____-____-__-gallons. 04 Septic 'Y ank—Liquid capacity........11"�'allons Length................ Width.......__._____. Diameter__.......____._. Depth._....._........ Disposal Trench-No. h idt .................... Total Length__.__.__..__....___. Total leaching area....................sq. ft. Seepage Pit No-------_------------ Diameter...__...._______.._. Depth below inlet___................. Total leaching area..................sq. f t. Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bv............................................. ........................... Date..................................... Test Pit No. 1................minutes per inch Depth of Test Pit_._.__.......__._... Depth to ground water------------------ rZ.4 Test Pit No. 2.:.............minutes per inch Depth of Test Pit__-_----_-____-_-.. Depth to ground water____-__................. .............................. ... ........ . ............ ---------------- ✓------------------------------------------------------------------------------ Description of Soil......................................�..,?Z ................ - ----- --------------------------------------------------------------------------------------------- U ....................................................................................................................................................................................................... ----------------------------------------------------------------- ----------------- ................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable..._............................................................................................ ..................................................................................................................................................................................... .................. Agreement: 4 The undersigned agrees to install the aforedeserked Individual SewagePisposal System in accordance with the provisions of Article XI of the State Sanitary Lod —.The , ned fuplier agrees not to place the syst I or-. operation until a Certificate of Compliance has beet! is ue the�owolk*k , led S, . ..................................... ................................ Date ......................................................... -----APPhcation Approved By ------ ....................................... Date Application Disapproved for the following reasons:............ ............m--------------................................11........... -----..I__....... ............................................... ......................................................................................................................................................... Date PermitNo....... ............................................ Issued.---............. ................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... ......................... .OF.....................cut ............. ............................................. (9rdifirat? of Tomplianno THIS IS TO CERTIFY That the,,Individual Sewage Disposal System constructed or Repaired Ott e/'F'ov.-C!-:- by......................................................................................... .................................................................................................. • . .. .....n ............ . .................................................................................at. .. .. ..................... .... ..... . . .has been installed in accordance with the provisions of Article XI of The State Sanitary Code as descobq.�Ljn the application for Disposal Works Construction Permit No ... —------------------- dated ---------................... *---------THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. 77 DATE................................................................................ Inspector..................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1A 4..,> ........... ... . ........... OF.----- r.. -- ---•--...... .. ................................ 0 No. ........ ............ FEE. .............. r Permission.js hereby granted...._.. ------------- .................................................................................................................... A . /w v, to Construct or Repair an Individual Sewage Disposal,,SystT,<, r&' at No......... 1..,4................................................................................................................................................................ Street as shown on the application for Disposal Works Construction Permit No..`'..,............. Dated.......................................... ........................................................... ............................................. Board of Health DATE............................................................ .......... ......... FORM 1255 Hcess & WARREN. INC.. PUBLISHERS