HomeMy WebLinkAbout1015 SANTUIT-NEWTOWN ROAD - Health /o a-
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No.. ........ J..... F;nc.... .... ...............
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ax�ALTH
OFFI-I E Ac T I-I T�,
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..............................:...........OF.......�.`.................... �. ..............................
Apptiratiou for Ui ipaaal Marks Tomitrnr tan Vamit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.................._------•--..........-=..'=-a . .............................. .......------ ---------- ...--- F
ff Lo tion-Ad r s - or Lot N •-------------------------------
t �7y.�.Qk ....9t -------------- --- �. ................... �D ��,__ F`._ ,
Owner Add
W -•••-•--•--_-----`�-`-'--1�..__. ..�� 1 .............................. ...........I 3�o / ...................................
-----•-....T---- =�?.•„-•----
Installer Address
dType of Building Size Lot____________________________Sq. feet
U Dwelling—No. of Bedrooms____.__..............................Expansion Attic ( ) Garbage Grinder ( )
`4 Other—T e of Building No. of persons____________________________ Showers ' / — Cafeteria
a' 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. 2................minutes per,inch Depth of Test Pit.................... Depth to ground water-------_........___:___-
a -• -•-
0 Description of Soil............ ` .....................:...................................................................................................----•---•-
x
V ---------------------------•--•••--------••- - . •.....-------------•-----------•------._...---------------•-- -
x ----•--•-••--.---•------------•--•--••-••----•----•-----•----.._..--••-•------ ---------- _..
U Nature of Repay or Alterations—Answer when applicabl .-__.UW_-.��--�-------------' ____
7eement:
- 9------ o � __._ .� .A
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iIi 1Z- 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.......... --.... ----•--- --•----•-----..__ ....-------------------•�-. .
.12
Application Approved By.................... - .....:� �t .....
Date
Application Disapproved for the following reasons:•.............................................................................................................
_
.......................................................-----------------••--------.....-•-•-------------'-----•---------•-----------------------...-----------------------------------------••••--_-••--
Date
PermitNo......................................................... Issued.......................................................
Date
Y
No — 7.:�� .. F.Rs.... ::' ..........
T1�IE COMMONWEALTH OF MASSACHUSETTN
a
BOARD OF HEA TI-I
.................................----.....OF....... ` f -••------
Apptiration for Disposal Works Tonstrnr 'pan .rrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: ,�
................................................ . °.•.. r ......._.................... _......__._...____......._.................. ............................. ...__.
............. ......
"ca� d+LtG --
f
.................... o ---. .............................. .......
Owner Add ess
.................... .........
Installer Address
Type of Building Size Lot............................Sq. feet U
.)--4 Dwelling—No. of Bedrooms......... ..............................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers V — Cafeteria ( )
P� 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 1px ( ) Dosing tank ( )
aPercolation Test Results Performed bY...........................................................................:.Date.........................----------
,� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
--••-•.......... -
ODescription'of Soil h ...................................................................................................................................
x `
W •-•--------------------------------•--•••-•-••••-•-••--------------•--------•-----•---•-------•------•-- 1
x �ice- " -----�' ----- '
U Nature of Repairs orb Alterations—Answer when applicable -------------------
.....--.....y
..<. !g—.. &a'G? C^js ......�' ✓-f ...... -•Pr'� '�4!/ ._...
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..,,
_-
.../
3 ✓`
Signed......._. f« _•ti ....................
'...
ate
Application Approved BY k' ;�r„ ..c. '' -- .----••--••--••------ ... ........?!e ram-
�' Date
Application Disapproved for the following reasons------------------•----------------------------------------------------------------------......---•--......-•----
•--•-----•------•--------------••--•--•-----•••-----•----••.....-•--•---•--------•--•........-----•-----•-•--•._..........•••.._....------•............................................................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
�. BOARD OF HEALTH
..............................
............OF................................................................................
Tntifiratr of Toutp ianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by...... =,;............ :�� ......... •- ' ----- --------------------------------------------------------------------------------------------------
H d1ler
ate==='�==......• �....l ..-.-� ;r ... ----.-----------------------------
has been installed in accordance with the provisions of TIT_LE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit .......... dated_..............................................
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 OF HEALTH
-�
No..c FEE....
Permission is hereby granted , --"'.......---•----. -......
to Constrt ct ( )ol:--Repair (10
nfIndyidual Sewag Disposal System
-, ,/%
at No.....:,,l�.t; �_-- _=r' •-- -------- -- -• -------------------------------------- --------------------------------------•-•---.------
A.... ! Street
as shown on the application for Disposal Works Construction it No..................... Dated..........................................
DATE ............... ...........................
FORM 1255 .HOBBS & WARREN. INC., PUBLISHERS