HomeMy WebLinkAbout0072 WINDMILL LANE - Health 7� 1N1 [r�rri i LL t- a-�-
LOCATION S WAGE PERMIT NO.
VILLAGE
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I A LLER'S NAME i ADDRESS
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G U I L D E R OR OWR ER
DATE PERMIT ISSUED 77
DATE COMPLIANCE ISSUED ,� .,_�-
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THE COMMOPIWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF.......... ----------•------------------------
Appliratinn for Dispati al Workii Tonntrnrtinn ramit,
Application is hereby made for a Permit to Construct ( L_�or Repair { ) an Individual Sewage Disposal
Systemd .� - f ------------- ...........................................
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n� Location-Ad;rr/ess i or Lot N .
Owner Address
..................
�ftt`e'r`••
$4 Installer Address i/�
UType of Building Size Lot__40_l�......_..Sq. feet
�-, Dwelling—No. of Bedrooms.__....................................Expansion Attic ( ) Garbage Grinder
aOther—Type of Building ............................ No, of persons............................ Showers (-a-) — Cafeteria ( )
a' Other fixtures -------------------------------- . -----------------------------------------------------------
W Design Flow................. . . ................gallons per person per day. Total daily flow_______1..0........................gallons.
WSeptic Tank—Liquid capacity./KOD._gallons Length................ Width................ Diameter................ Depth..0..........
x Disposal Trench—No..................... Width___...__._._....... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No....../----------- Diameter.._.....�G..'_....... Depth below inlet...., ........ Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing ( ) t
`-' Percolation Test Results Performed by.____ _. _ { ......(. VVnO/Alate.........-��.•._�_J3...._.
Test Pit No. 1.......2..... � C.
minutes per inch Depth of Test Pit.-�l�____._____ Depth to ground water____ .
Test Pit No. '.... ......minutes per inch Depth of Test Pit../Q. Depth to ground water.__��,T.
a -•••------••--------------•-••---------••-------. •--•-•-----------•---•----•--•--....----......----------•--•-------•••••••---•••--•-•-•----•--
0 Description of Soil-------------- G
----•-------------------•-----•---------------------------------•--•....•--•---•----•••--
x
W
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
--------•-----------------------------------------------------------•-•--------•---•---•-----.....----------....--------------------------------------------------------------------------------•••---•-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Dis osal System in accordance with
the provisions of iITA U 5 of the State Sanitary Code— The undersigned ther gre s not to place the system in
operation until a Certificate of Compliance has been issu by the board of i
Signed � .... - ---------------- n
Application A rove ----- -----...--••------------------------------•--....---------•---.......•-••_•-••-• --.7...�-Y.....
./•-------
Date
Application Disappro f r the following reasons-----------------------------------------------------------------•--------------------•-•-----•••---------•-_..._
...................•-•-••-•-----------------..........---------------•-•---••---------•--......--------..._..........._...--•----••--------------------------------....................................
Date
PermitNo......................................................... Issued.......................................................
Date
...... F�$...; !)............_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....... ..................OF...-............-...--.................--------------------......._...-•-•----.._..------•
Application for Disposal Works Tonstrartion famit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.................................................................................................. -----•-••--•--•--••-•••-------......._-••---------•-•--•-••--•-•-••-------•---•--...........-•---•
Location-Address or Lot No.
w ^
Owner......................_........................O ...--------•--•-------••---- -----•---•------ ..............................................
Address
1.4
(�
goInstaller Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e o: 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................
Disposal Trench—No_____________________ Width.................... Total Length.................... Total leachingarea....................sq. ft.
3 Seepage Pit No......._------------- Diameter____________________ Depth below inlet.................... Total leaching area..................sq. ft.
,Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Re-salts Performed by --------------------•------• Date
aTest Pit No. I________________minutes per inch Depth of Test Pit.................... Depth to ground water........................
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ---------------------------------•....._....-----...-------•------------.._..-•-.._...._..._•-----•..........................................................
0 Description of Soil.........................:.............................................•--------------------------------------------------------------------...••--••........I
W
----------------------------------•------•----••--•••--•--••-•--•---•---•----------------•--•--•••------•---•-••-----------------•-----.._--------------------------------------------------------------
V Nature of Repairs or Alterations—Answer when applicable...............................................................................................
„.
Agreement:
The undersigned agrees to install thetaforedescribed Individual Sewage Disposal System in accordance with
the provisions of T IT11' 5 of the State Sanit,,,r de—The undersigned further agrees not to place the system in
operation until a Certificate of Compliaceha +le., issued by the board of health.
Signed-.,:----.i........................................................................... ..•.--. ._._._...:...._..._
_ ..---,•".._,..- „,tom D -
ApplicationA rove •-• •••••--•-••----•-••--•••-•-...--•----•--------•----••-•...........................•-.....-- ...��F x-` -��--------
Date
Application Disappr r the following reasons:.............................................................................................Da.t.e..............
............................•-----•---------•--------------....••-•--•----•------•-....•-•--•-------•-------••-•---•._......•---•••-----•-•----...---•-•-•-•--••-••-------------•--•-•--- •-••-------
Date
PermitNo......................................................... Issued-----------------------•-.------....---•------....-•••--
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
�rr#i�irtt#�e �f ��r�t�rli�aa�r�e
THIS IS TO CERTIFY, T the Individual Sewage Disposal System constructed (Repaired ( )
..flow /-!C`-
bY `....... ---------- ---- -•---•-----•-•--------
nstaller
at_.;...
has been installed in accordance with the provisions of TITLE `�of T�,l-te State Sanitary Co as c bed in the
application for Disposal Works Construction Permit No._. %-'____ _____________ dated_-� __�-�__. __._______________.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE......................................./// ......--------------•---- Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
c ..........................................OF.................................................................. .
................
....................
Disposal Works ��arirrn
Permission is hereby granted.............Iff"Us��r
to Constr or Repair ) �ividua ewa ispo . em
-------••-•-•-•- f
Street
PP P T Permit . -•--•-•------••--• Dated_- /-_.......
as shown on the application for Disposal Works Construction_ �____•_
_ ----------
---•--•-...••---------••-------•---•--------•....-•....................•-•-_..-
.•------ Board of Health
DATE. l/�_-`�._._ ... -•---------------•-------
FORM 1255 A. M. SULKIN, INC., BOSTON
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OF 14R,
DAVID
THULIN
c: 1 No. 29976 c�
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