HomeMy WebLinkAbout0503 SANTUIT ROAD - Health 503 80Ir-hd-/z6acf
.> No.................. F�$.... . =a-�
THE COMMONWEALTH OF MASSACHUSETTS
_:`" BOARD OF HEALTH
®c"''"'.... - OF ................. .ffK.i �'!" .....................................
, ppliratinn -for M_q viial Works Tonstrnrtinn Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( Vj"an Individual Sewage Disposal
System at: ,
ryyQ Locat
&Ad ess or Lot No.
7L r
...................... ____________VZ___
r p //9//�J� ddr
Installer Address
QType of Building Size Lot..3..aJ--- P.d....Sq. feet
U
Dwelling/__�No. of Bedrooms__________________________ _--_-_____Expansion Attic ( ) Garbage Grinder ( )
aOther—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._____.,7.-------- Diameter------ __._....... Depth below inlet-_eo______________ Total leaching area-------.----------sq. it.
z Other Distribution box ( ) Dosing tank ( ) q h
Percolation Test Results Performed by.......................................................................... Date.... ._.--.._//a
��------ 'S`
a
Test Pit No. 1----------------minutes per inch Depth of "lest Pit.................... Depth to ground water...--------.............
LL Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground wa'ter_..------_____.____.__..
0 Description of Soil____ ______________ __
x
W ------------------------------------------------------------------------------------------------------------------------ ---------------
�xj Nature of Re or Alterations— nsw r when applicable._._ _`�.a_ .. _ .._. .._ .-.._._ i✓�-�'__. _________________
_ ..' - -"-------------------------------------------------------------------- --
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been 14suyrd by t ee board o lea
..... .... .................
Date f
Application Approved By------- -- ------------------------------------------------------------------------------- ------------ ' �Q-.• T�
' Date
Application Disapproved for ae following reasons---------------------------------------------------------------------------------------------•--'----•------'---- ..
-----------------------•-----------
------------------------------ ---------------------------------------------------------------
Date
.............. Issued-----------.....------ .................................
0-
Permit No.---------�--------------------..-� �
Date
Fus............................._
r THE COMMONWEALTH OF MASSACHUSETTS
K
4-BOARD OF HEALTH
N - of ..............:.. t I S'1 .4 ........----............------.
App rtttiun -fur Dhupouttl Workii Tonutrurtiun Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
Location-Address or Lot No.
�....... ......... .P�i—k.....
/� f) c.Oayner ffJ/f/f / sY Address
/,,^ �--- /,f^ �-----f-.--f_t�- '-----.G�s:.i___!'._
j f
t Installer Address
UType of Building Size Lot_ _ %.. _n_____Sq. feet
Dwelling No. of Bedrooms...: ................... Expansion Attic ( ) Garbage Grinder
a Type g p Showers ( ) — Cafeteria
Other—T e of Building ............................ No. of ersons_. __._.._._.__._._.__._.._
Otherfixtures ----------------•--------_. --- ••------------- ...............---•-•-----------------------------•-•--•----•-•------••----------•---•----•----
W Design Flow............................•-______-_____--gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity........_..gallons Length-_------------- Width-.-_--.-.._..--- Diameter................ Depth_.-.--__------
xDisposal Trench—No- -------------------- Width---------------------Total,Length--------------------- Total leaching area--------------------sq. ft:
3 Seepage Pit No......: .__._.. Diameter..... ............ Depth below inlet_.................. Total leaching area...::.._---_-___--sq. ft.
z Other Distribution box O Dosing tank ( )
~" Percolation Test Result Performed by-----------.............•-:-_---__-______________:_____._._._.__..._____ Date.... y: Z
a
Test Pit No. 1----------------minutes per inch Depth of "Pest Pit----------- Depth to ground water........................
�14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--------------------
--------------------------------------- ....
►x
O
Description of Soil---------------------------------------------------------------•-••---------------..._.--------------------------------------------------------------------------------
x
x --------------------- ------------------------------------------------------------------------------------------------------------------------- rJ
U Nature of Repairs or Alterations/Answir when applicable:-.-.f d 0_.0y! tx __-- ".. c1�--=----------------_..
---- -----------
.. i.
Agreement:
r The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI 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-
1,121 oil" Date
ApplicationApproved BY--------------- -----------•---•••--•-•-•-••-•-•--•-----•-•---•---•.:.-----••-------•----•----•• � }6
di -—_-----Date
Application Disapproved f or,the following reasons------------------------------------------------------•-------------------•---------------------------••--•--=
---•-•-------------------•----------------------------- ........ -----------------------------------'------------------------------ ---------------------,--------`----------------------------------
....� gate
Permit No.............................. 5 Issued........................................
-S
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
f :`?,.!.......OF........ %/". . ,, . .........................................
Qtrrtifirtttr of fuIontplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
p
Installer
�r
has been installed in accordance with the provisions of Article,XI of the ate Sanitary Code as described in the
application for Disposal Works Construction Permit No---------- ` - . ...... dated...........''?......`6......................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL �F/UNCTION SATISFACTORY. ,�t.AD
�
DATE l '�>�--t•VT..--•--•-••----------------------- Inspector------ --' 7 . .......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF(HEALTH
jdaA
....... .................................................................................... r
No........-- '........... FEE..... -•-L
�i��u�ttl urk,� �un,�trurtiutt �rrutit
r - t
Permission is hereby granted.................��........
._......___ 'r__.._
------••.••.•---••...---•--•-•--••---•-------•----•--•••--------------•-•---_..
to Construct,.( ) or Repair ( ) an,Individual Sewage Disposal System
Street . .- 7
as shown on the application for Disposal Works Construction Permit No.........a_....___. 7 57-
as .
^a4 ✓ /Board of Health
f
tW,
TE.---•.........................................................••--•--••-•-•---• ✓
'FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
LOC&710 5EW&C4E PERMIT UO.
e
V I LL-A GE
Ikwi51 LER 5 1.1' to ' 6 ADDRESS
15UILDE 5 I` &V,.AE ADDRESS
v' DI,TE PERNA T ISSUED --a�
t) 6,7 E COM P L I &MCE I SSUED — — —
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