HomeMy WebLinkAbout0202 BUCKSKIN PATH - Health ?0,?, o
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® I-IEAL�
.._.._.....O F..... .... .... ...... ...... .. ......--...--
Apphrattnn for Bifip ial Varkii Tnns#.rnrttnn Prrutit
Application is hereby made for a Permit to ConstruW- di
opair ( ) an Individual Sewage Disposal
syst at....* 11
.... ........ ...... . ...............................................
ocation-Ad a or IA No.
.... . . ....... ..... .......................................................................................
O ner Address
...... ... ...........•••••.•••wh.A..... ..................................................................................................
Installer Address
UType.of Building Size Lot............................Sq. feet
Dwelling No. of Bedrooms.......... '............:.....Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ............... No. of persons......................... Showers Cafeteria
Otherfixtures ........�-- ----------------------------------------------------------------
W Design Flow. .....................r3?.._ ..._.....gallons per person per day. Total daily flow-_._-_if5 gallons.
WSeptic Tank Liquid capacity............gallons Length................ Width................ Diameter................ Depth.................
x Disposal Trench—No..................... Wi �th._...... , Total Length._........_._._..._ Total leaching area....................sq. ft.
_------_-. Diameter .-.___ Depth below inlet..._._.......... Total leaching area.. � .sq. ft.
Seepage Pit No:../--.
z Other Distribution box ( ) Dosing tank ( )
a Percolation Test Results Performed by....................................
..................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit-------............. Depth to ground water-__--_._....•-____,____.
G=, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water----------.-------------
-- • -••----------- ---- --•--------••-•-----------------------------------------------------------
O Description of Soil-----------_____.._.. _ ._._.- _-_ ._ °
x
W ••••-••••-••-----------------------------•-••-•-•-••----••---•----------------------•..__...........----•-----•------------••---•---•-------• .........................................................
V 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 been issued by the board of health.
Sign .......--•................•------------......._..................••• •-•-•-•....
' Approved'By._ ...._...__......_.._
Application . � ,.. � ...
Date
Application or the following reasons------------- --------------------------------...........................................
PP Disapproved f
-----------------------------••--•-•-----------------------•----•-----•-----------------••--------........----------------------------------------------------•-----------•-•-•--•............-••••••---
Date
PermitNo......................................................... Issued........................................................
Date
- -------------------- ----�
No................I...... Fits..., . ..........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALT4
' .... . ... OF..... ............
-ApV iratiou for Disposal Wor onstrurtion Nerd$
Application is hereby made for a Permit to Construct ( or pair (._ ) an Individual Sewage Disposal
Sys t at
.. ... f .. ... ................ .......................... •----••••--•______________ ------
-cation Addr s;
or Lot No.
r
Address
. ....................... .. .......................................
.....- .. ............................................. ................................................
nsta er Add ess
UType of.$uildi'g., Size Lot............................Sq. feet
a DwelhngNo. of Bedrooms__..__. . .. .___ p ( ) Garbage Grinder ( )
.__ Expansion Attic
aOther.—;Type''of Building --------------_ ..... No. of persons.....____-,................. Showers ( ) — Cafeteria ( )
Otherfixtures ------........................................................ ---•- ._..------------...
W Design Flow -- --•......... •. .__gallons per person per day, Total daily flow._... F. -----------------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._ Diamett ' Depth,below inlet ..... ....:... Total leaching area _._sq. ft.
Z Other Distribution boxDosing.tank
aPercolation Test Results .. Performed IlY Date........................................
Test-,Pit No 1 minutes per,inch Depth of`Test Pit.................... .Depth to ground water...............•--------
-
w Test 6'Pit<No. 2___.__;_ __minutes per.inch' Depth of-.Test Pit_________________:_. Depth to ground water................._____--
. =
Description of Scil__..._.___ ^ � x
= ---•• ---- --- ----- -----•--=---•-•--••---------------•---••-----------•--••------- .......................
U Nature of Repairs or Alterations Answer when applicable....................................................................................._..........
... --••----- ----------•----....----------._...----------------------------------------------•-----•
Agreement:
The undersigned agrees to install the. atoredescribed 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 issued by the board of health.
Sired .......................................................................... -.....----•-•-
e. Date
Application Approved' By ~* .....................
*4—
Application Disapproved for the following reasons.---------------- •------------------------•---•--- ------. -----•-• ------------........
________________________________________________________________________________________________________._:_.:_..._..__._.______......•.____..________.__.•.._...__._._____.________...___.____._.......
Date
Permit No.........................................................
Issued..
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
T '" 1 CER Y; That the Ind>vidual Sertiage Disposal System constructer or Repaired ( )
bY� - ...ryry�y --. .-____ ...........................................
-f 1� 115taiICYti
at a = ............................................
f
has been installed in:'`accor`di tnce _with the provisions of Article XI of The State Sanitary Code as desc ibed in the
application for Disposal Works Construction Permit No------ " - -
dated __ _- . !.......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT RE CONSTRUED AS A 6UIARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE._.............................................................................. Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
,
BOARD HEALTH
..-:....OF.....
Permissio Zhereby granted. -=-- •i f-•--- ........................... ...........................................
to Const uc or Repair ) n 1 iv, u 4 age sposal Syst _
,,cc�� a •
at N y .._. ... ��.� � ........
...
......
.....
as shown on the application•for Disposal Works Construction rmit Dated..-_ Za
ar of FIc<
DATE............................................... -•------- ........................
FORM 1255 HOBBS & WARREN. INC:. PUBLISHERS