HomeMy WebLinkAbout0067 SCREECHAM WAY - Health l07 Ser�eckam
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LOCATION SEWAGU PERMIT No.
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VILLAGE -
I N S T A LLER'S „N. E i ADDRESS
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S U I L D E R ' OR OWNER;. :
DATE PERMIT ISSUEDd
DATE COMPLIANCE ISSUED �.
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THE COMMONWEALTH OF MASSACHUSETTS
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BOARD OF HEAL H
. . . .. ......... . . ........:oF......... n. ..---- ...
Appliratiuu for Disposal arks Tons#rurtiuu rrutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at*
... . -••--------------------- ..._--•--•--------•-- �� `--Lo ---- --- ----
Location r s or Lot
.......a_E
W FJ j -� .. .....!<... ...... ----- ----� .. ... --LEre�ss
(�
..
Installer Address
d Type of Building 3 Size Lot.__ � ____..____Sq. feet r
V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( J
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 capacityl..-..gallons Length................ Width................ Diameter_............. Depth................
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.....PAc1_74=A.............................................. Date----------------------------------------
aTest Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water--__-___________-______-
�TA Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
Ix •-------------------------------------------------------------------------------------------
--------
---------------------------------------------------------
0 Description of Soil........................................................................................................................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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 Article YI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been is�d by th and o ea h.
Signed............. -
to
Application Approved B
Date
Application Disapproved for the following yeas s:._------------ .............. ...... ...........................................................
.......... •. ... •• Date
PermitNo............................................... ....... Issued.................. ................................
Date
IL
No......................... .............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH, f
T
_..... .....OF...... t .��E f
,..
r
Alipfieatiutt for Ditipjasttf Works Cnonstrttrtiott Vautit
Application is hereby made for a Permit to Construct (/ or Repair ( ) an Individual Sewage Disposal
System at: d t Y j I t .-a.
i
•.
Location,A dress f j c or Lot to
p}}p IY fivner S r Address t
}
Installer Address
Lot.-
s S feet
U Type of Building "- �- Size Lot___.!��_"_____________ q.
Dwelling—No. of Bedrooms--------- .........................Expansion Attic ( ) Garbage Grinder
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..... t..'...... Depth below inlet.................. Total leaching area__-?t=....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by..... ------•--••----•---'--------•--------•-----•-•- Date-----•---------------------------•-•----
.aa Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_.-..-_-.------_--_.---.
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water----__----_-__--_-_---_.
0 Description of Soil--------------------------- ------------------•----....----•------------••---•---------------------------------....----------------------------------------------------
x
U •--•-••....•••---••---------------------•----•----••••----•-••--•----•--._........._.....-------------•--------•--•---•--•-••--•--••••-••-••-••-•-••-----•--•---•-------------------•------------------
W --•---•••----------••-•••---------------------•--•-----•---•-------•------•-••-----•-•-••---••--•-------•-•---••-------------------•-••-----•----------•--------------------------------•------••-•-----
UNature 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 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 t board of�, ealth ,?
Signed---------. __ �_---- -�� ---'"-`"�.- -------- ------ -. -:•-�.,�
Application Approved By------------------:---t---•-----'------ � ------•..... :.---- --------
------------------------------------------------
ate................
Application Disapproved for the following reaso;ns_..............
�_______._._'1.........._. ....... _
Date
PermitNo........................................--•--•=`--....t� Issued---------------------------------------•-- --•---
4 J Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..............................I...........OF.....................................................................................
T"Irdifirate of Toutplittttre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by-----------------` = ' -F ................................................. -..................
-
Installer
-----• = ; = =. ;..
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.....r :_7_:_. -If-_L___-P..._...__.. dated________________________________________________
THE ISSUANC OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A GUARANTEE THAT THE
SYSTEM WILL CTION SATISFACTORY.
DATE..... � 3..................................................... Inspector.----- ----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF........:...........................................................................
FEE... .1.............
�i����tt1 nrk,� C�lan,�#�ttrti�it >eetrtti�
Permission is hereby granted... ---------------..�y ...
to Construct (�) or Repai ( ) an Individual Sewage Disposal System ,
atNo.......... /G____ex C -^^----....-- ----------- . I...----- ------------------------------------------------•-------------------•--
Sttrr e e et
as shown on the application for Disposal Works Construction Permit No--------------------- Dated------.-----------------------------------
' P / Board of Health
DATE..................................... j t/
------- --------•---•---•-------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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