HomeMy WebLinkAbout0019 LESTER CIRCLE - Health (2) �����
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA TH
OF...... '................................................................................
Appliration for Dhiposal Morkg Tonstrurtion Famit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Systemat: I eel...................... ._.. .................. ..... ... ..... .... ............---.........
..... ... ..
Location• d ss - -
9 or Loo.
6 .................... ...... ...........:....... /...W...�.�....�. ...............
...................
W Owner •� �,p Addre
Installer Address
U Type of Building Size Lot.... �'ZlZ?....Sq. feet
Dwelling—No. of Bedrooms................ Expansion Attic ( ) Gauge Grinder ( )
W Other—T e of Building a Other—Type g .... ............ .......��IVo. of persons.............. _..._._.._ Showers ( ) — Cafeteria ( )
dOther fi tt�es ......................------------------••---•--------------------------•---------------•------....-------------•-•----•----••---------------•-----.
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.
3 Seepage Pit No--------------------- Diameter____.. epth below inlet.................... Total leaching area__,I.& .sq. ft.
Z Other Distribution box ( ) 136sing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-----_..................
4, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
O
Descri Description of Soil -_ ---- ...
xP -- ---- ------ ----------------•••----•----------------------•----•-•---------------•-------•---..............
V ......•---•--•--•-•--------••---•--•------•---••----•--•-•---•--•-------•--•--•---•-••------•--•----.....
W
x ----------------------------------------------------------------- .................................................... ---------------•--•--••------•-•---••-•--------••----•------•....---
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 Cod —The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ued by e a health.
Signed... _.< .�??:�. :.......................... ............................ ... .
Application Approved By......... / e a� -,,,,..,8 �
..,.. _� -
a. kate4
Application Disapproved for the following reasons--------------- - ,W� -
....................................•--------------------------...-------•-------•-------••--------........--•----------•-•------------------------------- .............................................
Date
PermitNo......................................................... Issued........................................................
Date
.a.L.. ----- --- - - �. ��....- ---------------------------
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No....... - Fix.
THE COMMONWEALTH OF MASSACHUSETTS
EOAR.D`OF HEALTH
F G�G 'I �..�.1h2• iid
Appliration for Eligpnsal N.orks Tnnit.rnr#inn Vardit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at ��;e1 _ t �
................ .�.. ..Location �1dd ss. 1 ...... ...... r` !. r• or Lots......................................................
.............................1..............................................
..... ... s........ 7 :. .......... ....................'...:: ........•... ......................................
Imay Owner + � s p! "Address
a ............................. ...... .............................. ._..__..__.. _.._.__. .._...._ ...,y _ ________._._
g
Installer Address
Q Type of Building -- Size Lot-----J S.__ '`I'-.__.Sq. feet
U Dwelling—No. of Bedrooms.................. ..•...:`.................Expansion Attic ( ) Garbage Grinder ( )
PA
Other—Type of Building ____ -----. .�nr!_e ___-Vo. of persons______________ ____.__.._ Showers ( ) — Cafeteria ( )
QOther fixtures ......................i --••-•......•---•--••--•-•-••-----••---••---..._..---•-••---••••--------••-••••••-------••-••----•-••--••---•--•-•-•.....
W Design Flow..............:..............................` gallons per person per day. Total daily flow__...____:!.1!�.....__._._.._.._.__._.____gallons.
WSeptic Tank—Liquid capacity/2 MY_gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No_____________________ Width..._„ _........... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No_____________________ Diameter__..__ ;a,w- Depth below inlet.................... Total leaching area___t1_:_._c: _sq. ft.
Z Other Distribution box ( ) D sing tank ( )
aPercolation Test Results Performed bv.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
r3:4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
ODescription of Soil............ _ x f `.............�=�:- ='t= �--------------------------•-------- . -------------------•----------------------------.
V
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 V0ued by the b�rd of_health.
,a, � ,.
ned _ .........................................................t
A lication A roved B MaA
t
Date
Application Disapproved for the folloiuing reasons__________________________________________ _________ r
----
............................................------------ -••••-•-•--••........_.__..__..._.....••_.._._.................
Date,
PermitNo......................................................... Issued........................................................
Date
THE. COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
y
s 't.�I.... ......OF....... �x,........� ......... ...41.....
OwIrdifira#r nrf (�nnt�rlt nre
THIS IS Ds CERTIFY, Thab the Individual Sewage Disposal System constructed, or Repaired ( )
L
bY---.........
- ----------------------------- --•-
has been installed in accordance with the provisions of Article XI_•,0lae State Sanitary f s d ctb in the
application for'Disposal Works Construction Permit No..._._ ._� .. _________ dated _ ____A '.___._______.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE COPISTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. w ,�
DATE---_....� -•?- 7_5.............:............................. Inspector._...
THE COMMONWEALTH OF MASSACHUSETTS
fps BOARD OF HEALTH
OF
NO......... '..:.... ... "" ... FEE ::............:.....
i n tr nrk � r� inn amit
Permission is hereby granted.......... �.
to Construct ( J),o e�air ( ) 4 I4ividulCSewagl Disposal System ""'I
l`
atNo................. ..........•-�_...' ,...�.r-..M s e�� ... .......t.. f.._......-------......----.......... .....................
C.✓ Streetr
as shown on the application for Disposal Works Construction Permit No.. �" 3. .....�'_...._... Dated. .. '�.... ... ..............
/ Y
'. Boardg Health
DATE.... = •-= � ............................................... ✓
FORM 1255 HOBBS & WARREN.' INC.. PUBLISHERS