HomeMy WebLinkAbout0140 SHELL LANE - Health L4D Sheu- La.n-L
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V\e, SEW1�_C;E PERMIT 1�10. .
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No. -. ........... imiic .... .:�........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF LTH
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Application -fur 43W.Vouttl Works Cnunutrurtiun Vrruift
Application is hereby made for a Permit to Construct ( ) or Repair (1-1*"an Individual Sewage Disposal
System at:
... ...................... .... ___---•---' -----....-•---------------------•--•-----•'-•---•----•-•'---------'--------...--'----...------•--
!....... o do dress ---` — or Lot. . o.
W er4r 4
Address
Installer Address
UType of Building Size Lot............_---------------Sq. feet
Dwelling No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type 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 ( )
aPercolation Test Results Performed by---------------- ......................................................... Date......... -------------------------_---
,a Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water-..---___-__-__.__.-_---
41 Test Pit No. 2----------------minutes per inch Depth of Test Pit._---___--__________ Depth to ground water------------------------
a ----------
ODescription of Soil--------- ---------------------•----------•-----•---------------------------------------...------ -------------------------------------------
x
U ---
W ---------------------------------------------------------------------------------------------------------------- -- ------
V Nature Repairs or Alterations—An er whe applicable._...._.. � /""' �® __._. .� � _._. [3..___.---
------------- - rs_t.@o. - Rr1�L``:
-------------------------------------------------------------------------------------------------------------•-------
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 bee issued by the and of health.
Sign
d !IGLG' '
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Date
Application Approved By-------I .� �6c7L r '.._------------------------- __' -7------------
Date
Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------
........-•----------••-------•-•-•••--------------------------------------------------------------------
[, ----- --Date-
Permit No......................................................... Issued.-- --r`,- ... --� t
Date
r 7N _.
NO.. �3 55 Fsa..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
`�ei .................OF.. ...-----'J
AVVIirtttiun -fur Rupunal Works Tonntrurtiun Vanift
Application is hereby made for a Permit to Construct ( ) or Repair (4<an Individual Sewage Disposal
System at
°f .__ ... ev ........-
....................................................--------------------------------------------
(} Lo ati ddress or Lot No.
b
�(�' ner (� j�? Address
((v// -------------------------------------
Installer Address
Q Type of Building/ Size Lot----------------------------Sq. feet
U Dwelling f-No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building -------------------------•-- No. of persons---_------------------------ Showers ( ) — Cafeteria ( )
G4Other 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 ( )
aPercolation Test Results Performed by------- ---------------------•-.......••------...-------•----....._--•... Date---------------------------------------
Test Pit No. I................minutes per inch Depth of "Pest Pit-------------------- Depth to ground water...-_-...-.----.--.-----
(� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground
water-...-.-----__-.---_-_---
- =--------- .-
t . ••- ---- ----- - - --- --------------------------------••-----------------------------------------------------------------
ODescription of Soil--- •-----� ------••-- -••-.......-•--•--•--••-•-•-•--•--•----•----•--•------•---•-•---------------••------------------------------------------------
X
U -•---•-•----------------------------------------------•--------•--•----------------------------••-•----------•-------•------------•-.-.---_•---_--------•-----------------------------------------------
Wx -•-------•---------`------------•---•-----•-•------•-----------------•--------'---------------------------------- _._. 4c------.- � ----------------•-------
Nature Repairs or Alterations—An er when aPPltcable...____. ��^�5
------------ -------------------- -- -- 2-- -----------------�-. _ ---------- : ---------------------
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)bDee issued b the oard of health.
Sig ed.. �Zs 1--- `!� t' �? �.- f -----•-•--------------•---••--
Date
Application Approved By, - !--(. /r ° df l/.��'_
Date
�� "_.-_Application Disapproved for the following reasons:....................................................................................•----.. --•--•-----•--
_--•-•------------------------------------------------------•----- ----------------•--•------•••-•••••---••-•-••---.....---•--•--------------.....-••--.....----------------••---------------------••••-
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH ,
..............OF..... . . ...............................
Tatifirnte of Tuntplinnrr
THI IS1 0 RTIFY, at the Individual Se age Disposal System constructed ( ) or Repaired ( )
by-------- = ----- = `� =
Installer
4/ �A i
at........... �• l-------
. ; �� y -- Er ----------------------- ------- ------- --
has been installed in accordance with the provisions of�Ttici`, XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit N ,?�. ____<: s.5`�...... 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
r /.
C; /..... �............O F...... �C1'rfd!' � -f
No. .....................
%rpinittl Wor , LIT n tr�trtiuit rrntit
Permission is herebygranted- ` �% -'<1'� - " . .-._....
to Construct ( ) or�2epai Pan Individual Sewage,Dispos System
atNo. l? �x -••••• .......... ': a..r,r- ---------------------------------------------------------------------------------------
Street
as shown on the application for Disposal Works Construction Permit No._____-------ef��. Dal -_ .
oa `�....,-_
DATE-------/� .
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B 'd e tTi t
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
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