HomeMy WebLinkAbout0151 BUCKSKIN PATH - Health (4) � �
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..........
THE COMMONWEALTH OF MASSACHUSETTS
BARD F HEALTH
G'..4. �� :..:........_..OF.......................
Apphration
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an
r
Indiv idualSewag
e Disp
osal
Sy at:
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---------- ------- .�J --------•-----•-----------------•--
C �•Address or Lot No.
Uo 7
.......i;. - -----------------------------e,4-------- --------=--------------•----•----
W Owner - /� C1 Address
Installer ;� Address
UType of Building Size Lot----------------------------Sq. feet
�-, Dwelling—No. of Bedrooms---_�----------------------------------Expansion Attic ( ) Garbage Grinder ( )
04 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- ____________________ 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 Test Pit.................... Depth to ground water...----------
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--..-.-..-_.-----_--. -.
9 --------------------- ------.................................................................................................................................
0 Description of Soil-----------------------------------------------------------------------------------------------------------------------------------------------------------------------
V --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
W
V Nature of Re airs or Iterations—Answer when applicable..-----�.� .��---_.---�_ " .----.._-- _�
--------------- - ------ ------------------------------------------------- -------------------
Agreement:
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 b n issued by the board health.
.... '" L
--------------- --------------------------------------
�/
,. ,�n Date
Application Approved By....... -- -- - ----- ---- - ---- u>~ _'�..7J--------
Date
Application Disapproved for the following reasons----------------------------•-•--•-----•----•--.._...........-••-•-••----•-----------------------•.........-•----
------------------------•-••------------------------•----•----------------•-------•-•---•------•----•----I--------------------------•---------------------------•----------•--•------------•-------------
Date
PermitNo........................................................ Issued.........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD E HEALTH
_.. ..._..........OF................................
Appliration -for Biiipwial Workii Cnaatatrurtiaa Punift
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Sy4Ti at
Loc ti -Address or Lot No.
WOwner � G (�
Address
( �/..........................• ............................................. G ..••--•-......----._........................-----------•-•--•-..................A...\........--
Installer Address
Q Type of Building Size Lot----------------------------Sq.\feet
U Dwelling—No. of Bedrooms------=-----------------------------------Expansion Attic ( ) Garbage Grinder
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )\
dOther fixtures ----------------••-•---•-------•--------•--•---------- ----------•-•--------•---------------------------•-----------------------------•-•--•.---•--
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity------------gallons Length---------------- Width.--_-..-_-_--- Diameter---------------- Deptlt.--..-._--------
x Disposal Trench—No..................... Width-------------------- Total Length-.--•-_-_-__--..__-. Total leaching area--------------------sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area_----------------sq. tt.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by------------------------------------------------------------ ------------- Date-•-•---------------------------•-.-
Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water.--------.--.----._.--..
f34 Test Pit No. 2________________minutes per inch Depth of Test Pit.................... Depth to ground water.-.-.-----._.--_-----.-.
fx ---------------------- -----.......................................................................•..................................... -----------------
0 Description of Soil------------------------------------------------------------------------------------------------------------------ -----------------------------------------------------
V ---------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------
W
- ------------ -------------_---_-------------------------------------------------------------------------------------------
------------
U Nature of ,
P airs
- 1_�epars or rations—Answer when applicable.._... '�''� ---/�'`-''-- %� -------
C7 to a ® ..
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 b -n issued by the board of health.
Sign d. �'4".`.."1:..--- ='j � i 7
Date
ApplicationApproved By.................................................................................................. ----------------------------------------
Date
Application Disapproved for the following reasons-----------------------------------------------------------------------------------•---------•--I..__._.____._...
------------•---------•-••-------•------------------•----•--------------------------•----------------•---•-------•------------------•---------•-------------•--•-----------------------••---------------
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............OF......� 0-47� '(—"' ...................
Cnrrfifira#r of f"ampliaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (4--)---
1 / Installer
atY ----------------•----------------------•--------------------
has been installed in accordance with the provisions of Artic4e XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No-- 7--------�.�.�------------------ dated ..................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS � /X4 ' �` r ✓/J/),
�s BOARD OF HEALTH
^.`' OF .... )...................................................�... , ..................
No......................... FEE...-:�"...'z...----....
�i��aa�1 ark, �g�catr�tr�ia$t �rratit
Permission is hereby granted.............. --------- .__._...---.---------_--------- .............................................................
to Construct ( ) o pair ( aan I dividual ev age Disposal Sys m
------------------------------------------------------------------
street
as shown on the application for Disposal Works Construction rmit �____ ___________ Dated-_-----..--._----._-----_-_____-.._----
---
Board of e51th
DATE
FORM 125/5/ HOBBS & WARREN. NC.. PUBLISHERS
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