HomeMy WebLinkAbout0030 CAP'N SAMADRUS ROAD - Health - -d�„As rz
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INSTALLER'S AME ADDRESS
UILDE R AR ONINEA
DAT— PERMIT ISSUED
DATE COMPLIANCE ISSUED
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_77------------ ---3 ' 1^*........OF......... -. ! ! .. .�1 E�. ..._-•---...._-•-..............
Appliration for Ubipaii al Warks Tonstrnrtiun Frrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
................- P�1...... AOAMv...- .----_j������_.---.._.. .........................................................
Location-A4iress r I of No.
• ...._C' "�a •-tf�1--1 ��`�cs .i.- . Qs `i_ i-tx._.1
f Ow er Address
a JAB ------------------------_---- t'" l `, � P1 o ..............................
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms.......... ....__.._.. _Expansion Attic Garbage,Grinder
(46
p`4 Other—Type of Building No. of persons........1N............... Showers Cafeteria ( )
a' Other fixtures __________________________________
Design Flow......... -----ILD ----------------gallons per person per day. Total daily flow....... _.. ..............gallons.
W G4 Septic Tank—Liquid capacity_1 gallons,,,�Length._._ _.__._ Width_.,-_________ Diameter_______________:--Depth_______.____._..
Disposal Trench—No.___�__�_._._._.___. Width___7 ___________ Total Length..__e l ........ Total leaching area---7.............sq. ft.
3 Seepage Pit No..... JDiameter........ Depth below inlet.................... Total leaching area...1 ft.
Z Other Distribution box Dosing tank ( )
~' Percolation Test Results Performed by.......................................................................... Date........................................
1.4
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........................
•---•-----------------------------------------------------------------•--•-••--•--•-......_...••-•-•.....................................................___-
0 Description of Soil........................................................................................................................................................................
x
c, ------------------
..
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 TITIE 5 of the State Sanitary Code— The undersigned furl er a es not to place the system in
operation until a Certificate o Com fiance ha been issue the boa of heal
Sig e lT[/
/� ••-[ '
Application Approved G'(�ff�_....
Date
Application Disapp, v o the following reasons:-••--•--•••••••--••••-•-•••••••••-•••-•••••----•-----••---••--•••--••---••••••-••••--•-••--•••-••-•--:....•-••--
L
Date
PermitNo....................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
4 ,
BOARD OF HEALTH
.........OF........'&RA5..�.�. .....-----.._--------------------------
Appliration for Disposal Works Tonstrnrtinn Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
0� � SA Js I
..... ....................� .....------. --- ............... ---------. � "'...1.a......---------•------------------------------........------------.
-. Location-Add ss or LotNo.
..... jT� t0 box.....a3-----•-• �►..'�......................._-
Owner Address
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedroom ............................................Expansion Attic (SIC) Garbage Grinder (0o)
P4 Other—Type of Building _ [ _ .. No. of persons.......�................. Showers (7Z4 — Cafeteria ( )
P4 Other fixtures ------------------------•--••... .
W Design Flow............11.n........................gallons per person per day. Total daily flow............. ....................gallons.
WSeptic Tank—Liquid'capacity f oo9.gallon Length____ -------- Widt -------- Diameter............... e ..............
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 (7() Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date.............................
-----------
aTest Pit No. I................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........................
-----------------------------------------------------------
......
.------------------------
..........---------------------------------
------------------------
0 Description of Soil........................................................................................................................................................................
x
U ---.....--••--------------•----••--••--•------•---------------.....................----------•-•-••......----------------------------•-•---•----------•---••••----•---•--••--•--•......---------------•-
W
VNature 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 TIT12 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance h s been issue i the b rd of�ie h.
Sined ` A ----- --------------- --------------
AApplication A roved,B ... .' '..................................'
PP PP �'
Date
Application Disapp'rou d` r the following reasons:----•---------•-----------------------------------------------•---------------------------------..............._
f
Date
PermitNo......................................................... Issued--------------------------•-••--•---------............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. .............OF....... ...................................
T rrtifiraV of TI-Im rliFatur
THIS IS TO CERTIFY. That the Individual Sewage Disposal System constructed (X or Repaired ( )
by.........Ali.+-+kq:�..........�-�r `� .......................----------------...-----
�1 In alter f� (b ��
at..........�Q-�....../®...........Ll �•---------sh.^�_��_s----------Y V 1
has been installed in accordance with the provisions of TI`�Lu 5 of The State Sanitary Coe a ribed in the
application for Disposal Works Construction Permit No..- "0k2*__-2- ?________________ da.ted�! : _._..,, ......................
THE 1SSUA
, . E O THIS CERTIFICATE SHALL NOT BE CONSTRII ® S A GUARANTEE THAT THE
SYSTEM 1A JL IJ ION SATISFACTORY.
DATE.-...( . � .....::...........•=---......------.......----- Inspector....-= ----• .....................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
jj �4...........OF..............XF
............._............
No .. r ....... FEE.......................
Disposal Works Tonitnulinn Prrutit
Permission is hereby granted...........A,..TI-O ..........f::Q)1'AkA.........................................................................
to Construct or Repair ( ) an Indi ,idual Sewage Dispo S stem
�' y t
at No.---••-•J"O.-.T P----•••-•....... -�-•--.....5t f!Y ..StretJS J�..... -----...----•---•--
street
as shown on the application for Disposal Works Construction Permit No.._..... "..... I) d/'. ...:. ....................
....................... �� �t ...
--------------------
BoardCof Health
DATE................................................................................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
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