HomeMy WebLinkAbout0106 GUIMQUISSETT ROAD - Health F
06' Gumquissett Road
COtUlt
A= 019 - 107 ,_
: e/9 /°7 �_
No...7-J�-..-S'71 Fps..... `....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................
a� ApplirFatiou for Btovoii ai Workii Tnnitrnr#iun Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: a ul'!1 u 1 SSa t�
- -----.- - --------••--------•--•----- -------------------•-------------.--------
ocation-Address or Lot No.
... .......�2 /���s�. &�....................
Ow e r `.. Address
----------.....................................................................................
-----------
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling]�'<o. of Bedrooms__......��...................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ......................................................----------------------------------------------------------------------•-------.............---•
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 ( )
aPercolation Test Results Performed by.......................................................................... Date-.......................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water--___-_-________--__---.
(14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-- ..... -- _ -
Descriptionof Soil..... ----- �'......................•---------------------------------•-•-----------•------------------------............................
r x
W ---------------...................................... -----------------------------------....................
// �j
U Nature of Repairs or Alterations—Answer when applicable-----!-'°_ _`�: ._._......_. !J ........
•-------•------------•------•-------------------•--•-------•--------...------------......-•----------------.....------------..............---------------------------------------------•---------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITA U 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee issued by th oar *healtgned ------ .�.��--.. ...._.. %.:
lat
Application Approved BY ... --- `---
� .. ................... ..._._....�----`�e
Date
Application Disapproved for the following reasons-----------------------------•----------•--------------------------------------------..........................
----•------------•--........-••--••------------------------------•-•-----•...---------•--....------........------•---•-•---------•--------•------------------•------------•------------ .................
Date
PermitNo..... ------•-•------------ Issued_.....................................................
Date
LOCATION EVVAIS% E PE RMIT NO.
4 L L A C E
,kA a tie
0 U 1@ a IE R OR 0WN EAR
DATE P E R M 1 T IS5VE,D_� - J �
GATE CAMPL ! 9-NCL 9S •940- -,D
Q 1
>> 1
�� � I
,�
I � � � � \
� �
N � ��/ � �
� i i � �� �
i f � � �
`,
�°�' �L��
i
.�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH fJ
tF'F .. OF........✓ I.. t; {,9' ,t
`� f
.� lirtt iaan faar* ispvs al Works Tonstrurttun Prrutit fi
Application is hereby made for a iPermit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at 1 ,
y
.......... ....................,.' ...............................•--.. ..........................................
.f Location-Address or Lot No.
........................................................ ........................................... ..............__...
.... ........
1 owner Address .................
Installer Address
Type of Building��r` Size Lot............................Sq. feet
aDwelling!No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
WOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures --------..........................................-................................. ------------
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
a ----•-------•----•----•-•---•--•---•-•---•----•-•-------------------•----- Date. ................................
Test Pit No. I...........:....minutes per inch Depth of Test Pit.................... Depth to ground water..................
GT,, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a
ODescription of Soil................ ='= ............ ----------•-------------------------------------•-------------------------------------.....----•----
U -•-----•--•---•--••-••-------•-•----------------------------••--------------------•-----•-•--------•-••----•----------•-•-.............................................................................
W ...........................................................-••--•------------------------•-----••----•----•-----
-----------
V Nature of Repairs or Alterations-Answer when applicable..._ "'.. 'y 'r '"
----------------------------•-------------------•-------•----------------•----------....--••----------------...----------------------------------------•-------------------------------•-------...--•--• .
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 be9V issued by the*board of health. % _
/
i ned ...A c ( Ys s`,> `'r lF� (ice �r ytd�
g .r ,r'o __._____ ._._......._° ___._. --1; (. 4
• r /
Application Approved BY ---- ----.• ` .............../fit!
Date
Application Disapproved for the following reasons-................................................-------------•--............................................
--•---------------------------------------•-----.....-------------------•-•-----.........---------------•-•-••-----------------------•-•--------...•-•---------•--------••••-----------•-•----------.-•-
Date
Permit No... w ._--��'---!_t
........................ Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9F HEALTH
01rrtifarFatr of f ourph atta
T' rTO r ERTIFY, That,fhe Individual Sewage Disposal System constructed ( ) or Repaired
bt, /
y....;e................ 1 `. f___ile E r f ....... ........ ........'.c jt'___._ .;�...y .f ....... ...... ..........
Y f I
r
✓ i J Installer
at--- -..... ...------ . '' ........... f`! ........................................................t r r ...
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.__r�: :... ? _!._._..... da.ted___. _I!,7165..................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL UNCT ON SATISFACTORY.
DATE..... -ram 6 ....... Inspector f (61tl�
...................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....�° `%`.:...: .....OF....�'''''.s ........................' .... ........� ................. b
FEE.Nr__..... ,�......: ... ....
����taaa3�a� aark� �aan��rUan aernt.�t
Permission is hereby granted...3,.zs......... ..... f � ` �� +f+� � %�` ' �"% e"
to Construct ( ) or Repair, (s an Individual Sewage Dxsp'osal-.System -
Street
as shown on the application for Disposal Works Construction Perwi L�& � �....__ Dated_ _ i_h��.. '` .............
4-.
....................... -- _ :-w- ..............................
\- r (�G� Board of Health
`� DATE----- _..../ ..........................................
------------•-•------•-----------
FORM 1255 A. M. SULKIN, INC., BOSTON