HomeMy WebLinkAbout0023 GOOSE POINT ROAD - Health 3 67oOS-2-'PC) Imo'
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No....:1.`�./. Fes$.. f . ....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAL_TH
.................OF.... ...............................
a5a_ e�A.VV irn#inn for Uispsal i9orks Tonotrurfinn Virntif
Application is hereby made for a Permit to Construct ( ) or Re it ( ) an Individual Sewage Disposal
Syst a
.Location-A• r ss ;,•..... •..-•.- � `� �� l Lo o. /_ ���o
s..: � -
Ow er dress
Installer Address
QType of Buildin Size Lot............................Sq. feet
v Dwelling7No. of Bedrooms.........___.........................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons............................ Showers — Cafeteria.
a' Other fixtures ________________ _ ____ _ _
W Design Flow............................ ___gallons per person per day. Total daily flow............... -----------
gallons.
WSeptic Tank—Liquid capacity/el.I'igallons Length................ Width---------------- Diameter-----__--------- Depth................
x Disposal Trench—No_____________________ Width.. �} Total Length----------- ........ Total leaching area_._..rr�..._.__......sq. ft.
ter
Seepage Pit No......./------------ Diame ....(Depth below inlet.......4......... Total leaching area._ ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by........................................................................... Date........................................
Test Pit No. 1........_.......minutes per inch Depth of Test Pit.................... Depth to ground water.__....._-______-_-._--.
fs Test Pit No. 2................minutes per inch Depth of Test Pit _..____._.__._..__ Depth to ground water.......................
O Description of Soil.............. - - - . -
x
•-------•••---------------------------•-•--•----•--••-...-----------•--------------••--...--•-----•-•-------....---------•------•-••••.....-•-•----•-•-••-•----••••---•--..__._.__..__-----.._......._..
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 undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been • su � b the board f health.
Sign �t �4
. _ __..
4
Application Approved BY . •--• -• f $- g.
• Date
Application Disapproved for the following reasons--------------------- ---•____.____._____....--•••------------•-•--_._...-----•-•--••-••----•....-••------•_.....
------•----•--------------•--•----•-••--- ---•-•-
..-•-•----•----------•------•-----........................................................................ - Date
Permit No......................................................... Issued � ., -- Date
Permit
Date
y:
>a a
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
r *'
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an .Individual Sewage Disposal
Sy!st7 at~ Z
51
-----
� Jf p
s� Location•Ad r ss air r
....+�.�..a....?a.�. .' .. " `'",'�.'..�:..... '.' e{.; 5: F..:................
J •! at ,¢v"err .L:. �j1�y4� �syY .oF�✓6ra ,.._._
r Lot P
.0114 . .dress
� ....................................... I...aAer .......f! .........................Address. ........................_............
Type of Building Size Lot................ Sq. feet
», Dwelling;No. of Bedrooms....... .. .. .................Expansion Attic ( ) Garbage Grinder ( )
a e
� Other—T YP of Building ---------------------------- No. of persons...................-........ Showers ( ) — Cafeteria-(-----)-
� Other fixtures --- --------...........................................................------
W Design Flow.................... .... 40...gallons per person per day. Total daily flow................ ..........gallons.
94 Septic Tank—Liquid capacity`,o`° gallons Length................ Width-_--..._.:---___ Diameter................. Depth................
�141W Disposal Trench—No. .................... Width_..:_........... Total Length._._.....__. _...... Total leaching area....................sq. ft.
Seepage Pit No.......j----------- Diameter. _: -Depth below inlet....... ....... Total leaching area... .. . ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date.........................................
Test Pit No. 1----------------- per inch Depth of Test Pit.................... Depth to ground water:_____-____-:____.__._-.
fTq Test Pit No. 2................minutes per inch Depth of Test Pit ------------------ Depth to ground water.........................
- - ---=---••------------------------------------------=---------•------•-----
O Description of Soil----•-... ••- ~R f _ ._:_:
x -----------------------------------------------•-------•-----•---------•--
U .......................-.................................................................................................................................
W
UNature 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 NI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ssue bjj
y the board f health.
!.* Sign _� '; q ,n x �'
Application Approved By...... '« I , �
Date
Application Disapproved for the following reasons:...... ..............
-----••---------•-••••---------•-•----••----------------------------•-----••--•--.....__...--••-----...:.....-•-.....----.....----•---...---•..::-••---------..........................................
Date
PermitNo......................................................... Issued ` . ' ....................
Da e
THE COMMONWEALTH OF MASSACHUSETTS
BOARD JD= HEALTki
..
wrrtxliraatr Lit (Ijaaaapli aatrr
TH IIS tr` CEPfIFY, That the�In idual Se pa Dlsp sal System constructed or Repaired ( )
j ........
.a„ �
---.......--•-
f!`1� r r` s8 vZr._a" ....:......................X
at......e� ".______ tc
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit -No-------------------- _ ---------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS Ai GUARANTEE THAT THE
SYSTEM WILL FUtJCTION SATISFACTORY.
......_.... Inspector :=Z/�_:,)
DATE........... ,�.. ��' � �" .._� - .�... ': ���'��--;r ......
s-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ,,OF HEALTH
No. ... .....:. off .._.. ' e.
'` 44#412 FEE..-.
I
Permission is herebygranted......
� . 1 .,..
toxConstri, ageispo� u Sallyst
atai
N ,. ` '
....
Street 7
as shown on the application for Disposal Works Coust_uction P;7i1 1�it NO. :.. s Dated--'.,- .. .
}. . .. "^^' �.. .s`,r? e. --- ; �'-E'.. .. �.........................
E, str }3oard o�Ilcaith
--- --- ---`-- ..............................
FORM 1255 HOBBS & WP.RRF..N, INC.. PUBLISHERS