HomeMy WebLinkAbout0020 DANIELE STREET - Health (9-0 OCLO e � �—
LOCATION / SEWAGE PERMIT NO.
wS
74
VILLAGE
I N S T A LLER'S AM,E i ADDRESS
c kka
B UILDEIII OR O ER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
Ll
31
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I v A�
DATA
j.
No............. Finc..........*......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
rt
................... .....................�OF................................:.........................................................
Appliration for Disposal Works Tilustrurtion "rrmit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal.
System at:
......................... .............................................. ..................................................................................................
Location-,Address or Lot No.
....... ------------ ----------*-------------------------------------- ----------------------------------------.........................................................
Owner -Addressi'
� ................................................................................................... .....................................................................0............................
go Installer Address
Type of Building Size Lot...........1--1.1----------------Sq. feet.
U
Dwelling—No. of Bedrooms......::....................................Ex ansion Attic Garbage Grinder
Other—Type of Building ............................ No. of persons...._......._............... Showers Cafeteria
Pi
Other fixtures ..................................................................... .............................................................................
Design Flow.............................................gallons per person per day. Total daily .......................o........gallons.
134, Septic Tank—Liquid capacity.......:`.,.gallons Length-............... Width....'.'--I Diameter..._.........._. Depth................
Disposal Trench—Npo.................... Width....._.............. Total Length........_,.._.__.... Total leaching area-___-...............sq. ft.
Seepage Pit No...................... Diameter...._`.....__..__. Depth below inlet.......I............. Total leaching area ft.
Z Other Distribution box Dosing tank
1-4 Percolation Test Results Performed by.......................................................................... Date........................................
1.4
Test Pit No. 1................minutes per inch Depth of Test Pit.__........._...._.. Depth to ground water_._____........_.....__.
(r4 Test Pit No. 2................minutes per inch Depth of Test Pit...___._....__..._.. Depth to ground water......._.__._._........_
............................................. ...................................L...............................................................
0 Description of Soil.......I..............................................................................I.................................................................................
............................................................................0...........................................................
U 1-�----,:---.7�----.!�.,.....:-�.....................................
.........................................:.................................................................................................................................................................
U 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 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,issued by the board of health.
Signed------............................................................................. ...............7
..................
Date,
ApplicationApproved By.................................................................................................. ----------------------.................
Date
Application Disapproved for the following reasons:................................................................................................................
......................r..........................................................................................I......................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF....................:..................................................................
TO Wrtif irttt of Toutpliattrr
THIS IS TO CERTIFY,_That the Individual Sewage Disposal System constructed or Repaired
by..........................................................................................
_-----n.............. m....................................................................7............
Installer
at........................ .................................................�*.. .......................................................................................................................
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.............................7....................... . . . Inspector..
il!..... .........C.......................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................................0 F...7...........................................................................
No......................... FFE........................
VIM Disposal, Works T Vn frrmit
Permissionis he. granted..................................................................................................................................=...........
to Construct or,Repair an .Individual Sewage Disposal System
atNo................................. ................
...........................................................................................................................
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated.._.._....._.___.__._...__...............
.............................................................................................. ........
Board of Health
DATE................................................................................
FORM 1255 A. M. SULKIN, INC., BOSTON
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E
-IOTA t- DEePIGN - 425 G.PD. Q 7-4=,
TOTAL DA t�Y F�-ow! = 33o G.Po y9 ;l/may;' :
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