HomeMy WebLinkAbout0306 LONG BEACH ROAD - Health (2) No........... Fps. . .............
10�
_ ,n 13 Sce THE COMMONWEALTH OF MASSACHUSETTS
l BOARD F HEALTH ��?? �
�� .... ... . .....O F... .... ............. ..... Lf�" ................
Aplifiratiuu -fur Bi,ipuutti Works Tuuitrurtiuu Vrruuit
Application is hereby made for.a Permit to Construct ( ) or Repair ( )�dividual Sewage Disposal
System at: v�
_...__!1./_ `.'_'_�p_______ ._•—•-•&........ ............... ---••------------------------------------------__
ion resdcT s or Lot No.
f
caner ........-.........................................................................................
Address
In ller Address
Q Type of Building Size Lot----------------------------Sq. feet
V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
0.' Other fixtures ----------------------------------------------•------------------------------------------------------------------------
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 ( )
Percolation Test Results Performed by....... ................................................................. Date---.----------------•--•---------------
a Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water---._-.-_----.--.-----
f4 Test Pit No. 2--_.---__-_____minutes per inch Depth of Test Pit____________________ Depth to ground water------------------------
P4 -----------------------------------------------------------••---•--•-•-•..........----------------...------.....----....--------------------------------•---
ODescription of Soil................................................................ ---------------------------------...-----------.-.---------------------------------------------------
x
W -----------------------------------------.......................................... ---------------------- --------�-
U Nature f Pepai or Alterations—Answer wh n pplicable.- -~ -'�c!�'J'?-Q� '�'�
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 n issued by the board healt
g � ! - / 7 �'
Si d ffwl-lt
�-'`-�' Date
Application Approved By.__.. �4 7 l- -�--------
Date
Application Disapproved for the following reasons:----••-----------------•-------------•--- -----•---------...._..._....---------••-•--•--............------_.....
..-•--•-•----.....-•-•-----------•-----------•---•--•--.•--•--------•------•----------------•--•---------.............--•-----------•--------------------......--•---------------....------------------•-
Date
PermitNo......................................................... Issued........................................................
Date
--
No...........
_...__.... ......-. .
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® F HEALTH
-�.- ✓�' .r'''----.OF. _:.Vv 1_o.........
Ap.'pliration -fear Biipuiittl Workii Tontitrurtion Vrrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( )fan Individual Sewage Disposal
System at:
-cam-------------------------------------------------
ion-Address V or Lot No.
r
Address
E �wpe1 ............................... ••.
f In ler :; Address
UType of Building Size Lot__________________________Sq. feet
Dwelling—No. of Bedrooms____________________________________i__.--__Expansion Attic ( ) „ Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of Pei- us---------------------------- Showers'(v,,) — Cafeteria ( )
Other fixtures ----------- „`
W Design Flow............................. gallons per person per day. Total daily flow _._ ..................gallons.
Pi Septic "Tank—Liquid capacit�v � __gallons Length __.__._._._. k'Vidth.. Diameter ,�. ._ Deptll ---._.--- .
W
x: Disposal Trench—No._____.__.. Width___ Total Length................... Total`1'eacliing >acz.._ sq. ft.
e.
3 ` Seepage Pit No..................... Diameter----------------------- Depth below,inlet .=_. __.__..:__ Total lea.161 ig area ._ ..-.._ _____-sq. ft.
z Other Distribution box ( ) � W Ding tank ( ).
t
Percolation Test Results Perlformed,by _______________________________ Date__
Test Pit No. 1................minutes per inch Depth of ^Ptst,Pit.................... Depth to ground water ---------------
f� Test Pit No. 2................minutes per. inch;"Depth of``fest Fite;-------------- Depth to ground water
G �
Description of Soil r
.____________________________________________________________________________________ .-___--__-_.-_-____ ._
Ws !
_______________________________________________________________________________________________________•_._._- _ �._. s
U Nature f P.epai or Alterations—Answer w;;,;h hcable._. .. __ ���1 i�. L. Gg t,. ___--.
�+ •--•--•----------- ---- - - - ------
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 bernNissued by the board,
h a
C- J J
Sigd , . ................ _..__. . . ! ---• •-!--------------------------
Application
.Approved BY -- -- . .. t_` `7 -------
Date
Application Disapproved for the following reasons------------------------------------------ ----------------------------=-----------------------------------_-=--
hr
...............
Date
Permit No------------------ ----- Issued.............
..sk-
1` ,
�,•. ., ¢' Date u
` THE COM4O.NWEALTH OF MASSACHUSETTS 4
-.. BOArRD OF - EAL�TH ;
........OF.
�rrt firatr of 101uutpliana
THI O C TIF That.t Indiv` 7al Sewage Disposal. System constructed �(,, ) or Repaired/
Y
b ---------- r Anstallr �" !L
at. = 'y7�- - ----__--`�+ l _----- t
••--
xt, has been install( JA accordance with the provisions of r e ri]a s de-sced in the
application for Disposal Works Construction Permit No,,.. ._.__:-�--a _______________ dated._.:!"_._.....................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM,M"ILL FUNCTION SATISFACTORY.
DATE_---•-----------------------------------------•---------..'--------='--•------- Inspector......................................... ='
THE COMMONWEALTH OF MASSACHUSETTS
�..:./ 'BOARD Cff HE TL4 !L
L,,,,,�' ...... .. O F..... �.
• - �i>a��r�ttl rg CIT trttr ioat rrutit.
Permission is hereby granted__. __:. _ _
to Construct A Rep tr ( an Ind idu Sewag tspo S e "
at No._..__.. {rq,' � X --;-;---- - --------
Street
as shown on the applicatioq,for" po's`a1J Works Construction it N ...... Dated -' .''�
Dis ---------------too
r'
2
w --------------------== --' d of a i/ Boar t�
DATE:'--�-�--�"' 1
FORM 1255 HOBBS & WARREN, INC.-, PUBLISHERS -
��
.r,i�
�,
'�
..
��
�`�+�
+ `'�
�.
�, e'
` 1