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HomeMy WebLinkAbout0081 CROCKERS NECK ROAD - Health t7 T,. LOCATION �� SEWAGE PERMIT NO. VILLAGE I N S T A L L E PS KA_ E a ADDRESS --BJJ R OR OWN ER DATE PERMIT ISSUED , c`i� DATE COMPLIANCE ISSUED l 3�. .e � i'J ��� .� '`` �` � .' No.. ©.... Fxs.... ..... 4 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .................... ................O F.......................................------.-----.......------------------------------ Appliration for Uhipoii al Works Tonotrnrtion Vanfit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at• c .... �.. ...�!�-�: .---..... --------- --------------------------------------------- ......................................... Lo....catio.n-Aft or Lot No. ...�� . ... .. ........................................ 9.. ... s......,........... aW ..... . i- . .._�_. ........................................ .. -.- e. Installer Address Type of Building Size Lot. - ....Sq. feet aDwelling LNo. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) p-, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' 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........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ GT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water___________-.._..__.____ a O Description of Soil... x W ---•----•-------------------------•--------•---------------------------•---------•----------------------- pp -- txj Nature of R pairs r teratio —An w r when applicable. F_----1 .. � . ------------------------------------------------------------------------------------------------------------------------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT1L 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been d by t e board of beaJth. Signed ---•---•---•-------•-- ..........................--.... Date Application Approved By----- •-1... . ............ .....------------------....--•-------•-••------ --------..0�1<`.!L`!...._._.. • Date Application Disapproved for the following reasons---------------••----•-•---------•-----------------------------•-----------------•---....---............_-------- --•-----------------------••------•----------.......-----•--••--------••--------••---•--•--------------------•-•--------------------•-- ---------•-•--------------•----------------•-----------•-----•-- Date 6, Permit No..... .-.°f _ Issued. -.... - Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................O F..........................................----------......-----------.._................-- Appliration for Bisposal Works Tonstrnrtion ramit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System. at: F .......: -•--- .........---••-•---...---•-••--•-----••-•--•-•---••-------•---•.........................•--•------ ocation-Addre --or Lot No. .. "_.K il:F-...l...G.... ...... ............................. ................�.F................. _ ........... ........... ............. �1 ..... ner ..... .�'i.: .. dress & Installer Address Type of Building Size Lot. tQ .....Sq. feet Dwelling IONo. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) PL.IOther—T e of Building No. of persons............................ Showers — Cafeteria p`I 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........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. a...............minutes per inch Depth of Test Pit.................... Depth to ground water........................ ae ODescription of Soil.... t l`�`= ------------------------------------------------------------------------------------•--.........._.. x W --••-------------------------------------•-----•----•----•--------•-•-----------•-•-••-••-------•-•----------------------------•••---•-••-----------------•-----------•---------------......-•------- UNature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------------•---•-------------------------..-....................--•-•--•-••----...-----•-•--•-----------------------------------------•------------•--------------------•--•---•------. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with tlfe provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is ued by tyeand f health. ---------------- ZMSigned ........................ --•---••----•------•-- -----_--- . �� s Date Application Approved BY -- ---------------------------•------------------ .........! -l16 /-.-f.......... Application Disapproved for the following reasons---------------------------------------------•---------------••-•-----------•-------------•---••----------...••- ----------------------------------•-•-----------------------....-----•----------------------------.....-----._........_..-•-------•------------------•_------••-----------•-------•--••---••--------••-. Date Permit No..... G. g .... Issued-_M-d.-•-•--&--------_-•••-••••-••-••--•-•-•--- Date Tli`E COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF...................................................................................... ®At rwrtif irtttr of TontpliFanrr THIS IS TO,.,CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) b ,rr-------------••-•••- Installer at..-•--ems-•-*------- ----& e"O.- 6 has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY.° DATE..._...... 1 .. . .`? ............••........ Inspector---•- s .............. THE COMMONWEALTH OF MASSACHUSETTS r BOARD OF HEALTH ...........................................OF....................._............_................_.._..........................._.. y a No-.4 .-�.d.C� FEE... l�.......... " ~ Disposal Works Tonstrudion amit Permission is hereby granted------ ....Gz,(.. '' ----•-------------------------------------------------------------------------------------------------- to Construct ) ors Repair ( ) an Individual Sewage Disposal System at No.---... { f72GK�' ......�-&-•-i.. ##` '' -------_--- Street as shown on the application for Disposal Works Construction Permit No._ !_ '2l?._ Dated.._.P_0.�_lbjew.................. ' .G------------------------------ vK Board of Health DATE................................................................................ FORM 1255 A. M. SULKIN, INC.. BOSTON