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Home My WebLink About0021 CONTENT LANE - Health a 1 C�n�-end- L�-r►� C Fim THE COMMONWEALTH OF MASSACHUSETTS E®ARD Of HEALTH �...........OF.......... -- ----------------------------------ll.�........_-_- AppWation for io#aia1 19orks Tonotrurtion rantit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst at: ��9 L��-- : 1. .. ° -............ ion-A � ------------------------------------------------ ,........ fa No. wrier Address /..�tlddress Installer Address Type of Build - - Size Lot__________________.________Sq. feet aDwelling—No. of Bedrooms______________________Expansion Attic ( ) Garbage Grinder ( ) pi Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures __.___ .r.. W Design Flow�'•••.............` ••_. 4. allons lions per person per day. Total daily flow gallons. WSeptic Tank Liquid capacit _ _ Length................ Width................ Diameter.......--------- Depth................ x Disposal Tr nch—N _____________________ Width............... __ tal en ._ ...... ._. T al leaching area....................sq. ft. Seepage Pit No.----7 Diameter . -- w et.................... otal 1 Ching area. sq. ft. Z Other Distribution box ( ) Dosing tank ( ) __K`2 _ � Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................:___ Depth to ground water........................ -Test Pit No. 2..............__minutes per inch Dep i of Test Pit.................... Depth to ground water........................ a' ---------------------------- - •- -•-• • - ••-••-----------••••----•••---••-•-•----•-----••------••----•-•---------•-••-.......---- x 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 Article YI of the State Sanitary Code— ur ie not to place the system in operation until a Certificate of Compliance has be • ued " oard h It . igne ••• ••••. -•- •••.••• -----------•••--- -•••••• - ....... •-/ T------^-DIfa ---- ----J'-�•-- a�e Application Approved By--•----- -- ....... . ........ Application Disapproved for the following reasons-...............................• ••--••-.--••••--•--•• -•••--••-•••-•-•-•-•--• -------•......... ......._-•-•--•-•.._..-•-•--••-••--•---.......•--••--•--•-•••••-••=•---•-•-••--•......--•-••-----•••-•--•I•--------••-•..._..---•---••----••••••-•••--•--•-••-•--•-•..............•--•••--•••--------••-- Date PermitNo.....................................=----------................... Issued...-- ................................................. Date -------------- -----__•-_.__- --------- -------------------------------' No.....1.6-knX. FEim... ....................... THE COMMONWEALTH OF MASSACHUSETTS BOARD QF HEALTH ...........OF........ - -- -------.....____............ Appliration for Bitipmal Works Tonotrurtion vormit Application is hereby made for a Permit to Construct or Repair an Individual Sewage.Disposal Systepa at: c ion-A 'Ste........................ ............4 e4,e ................................................. Lot N LOW ............................. ...... ...... ................ 0, ... wne, Address ............. .... ... ........... .................................................................................................. Installer Address Type of BuilSoar- Size Lot.........:..................Sq. feet Dwelling—No. of Bedrooms_.._..__._. ....................Expansion Attic Garbage Grinder ( Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( Other fixtures ......I--------------- ----------- - ----------- -------- ----- ------ ......... ... ..........Design Flow- ...... lions ---person per _gallons. ---------------- ;4e _ p --------------------- P4 Septic �a' Liquid capa'cit -".,allons Length................. Width---------------- Diameter---------------- Depth................ Disposal Trench—N ..................... Width............ ota,l en leaching area....................sq. ft. Seepage Pit No. -------- D me ow.; let ....� 6tal 1.%tching area..................sq. ft. ia ' te�P----—---- Z Other Distribution box Dosing tank Percolation Test Results Performed by ------------ ----_------------------- .................................... Date........................................ - . Test Pit No. I................minutes per inch. Depth of Test Pit.................._ Depth to ground water...._..............____. Test Pit No.'2................minutes per inch. -Dep of Test Pit.................... Depth to ground. water........................ . ......... P4 ............................ .. . .... .............................................................................................................. 0 Description of Soil-----------------....................... ... .... . . . . ......................................................................................... ........................................................................................................................................................................................................ U .................................................................................... ................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable................................................:... ......... .........I................... ......................................................-Vh................................................................................................................................................ Agreement: I k The undersigned agrees to install the aforedescribed Individual Sewage Disposal-System in accordance with the provisions of Article XI of the State Sanitary Code I, I 'n r. ier not to place the system in operation until a Certificate of Compliance has be ie ky,"th'i oard h lth ign ... ..... ... ........................... ------ ------ ------- Date Application Approved By....... .. ......... . ........ ....... ............ Application Disapproved for the following reasons:�... ............................ ............................................................................ ......................................................................................................................................................................................................... Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF NEALTH ...............r .. .......OF........... .......... .................. 'W"IMfifiratr of, Tompliana THIS IS CERTIFY, Tyat the Individual Sewage Disposal System constructed ( ) or Repaired ( , I 0 by----------------- 1'_0 e.1 L w.... ............................................................................................................ Installer at_.............. ... . ........ .......... .................................................................... has been installed in accordance with the provisions of Article X1 ofjThe State Sanitary Code as des g(ibedjin the application for Disposal Works Construction Permit No....... 11�..jY.................. dated------------------_I/A 41- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................. Inspector..----.—........................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD qF HEALTH ....................................OF...... ... ...................................... N ........ FEE.4h................ Diapos rk it frrm Permission is hereby granted __k!. nstru, Jai ff ........................................................................ to Construct-J, ) 0��.......... pair ( ) an Individual �ewage Dis S IF at No....... A .&- ...... ..Street as shown on the application for Disposal Works Construction Permit No.44 7-orl.. Dated________._. .... .................................................................................................. Board of Health DATE................................................................................. FORM 1255 HOBBS & WARREN. INC., PUBLISHERS 0 � o d M �7 t 6v 0