HomeMy WebLinkAbout0039 CANTERBURY CIRCLE - Health _ _/-p_.. � __.
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THE COMMONWEALTH OF MASSACHUSETTS
BOARDr. H EA
I _r000pk.....-....._OF........ ... -----------------
Z Appliration for 15isp.osal Works Toustrurthi t Vantit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: do
.......... .......
..Location- dress 4r"i ot No.
.��. .!t.:. - �... '� ' ..........
'Owner j��j Address
i ...... c.� .:. t ...%T ! iz ....a .......... ................
Install Address e� "
UType of Building � c � Size Lot.......16...9' ....Sq. feet
Dwelling—No.'of Bedrooms...............3..............._.........Expansion Attic ( ) Garbage Grinder ( )
a Other—Type of Building No. of persons !/...-.: Showers Cafeteria
a g P , - ( )
QOther fixtures --------------- ---------------•••------•--•--•----•--•--------•--------•--•---••---------••--------
w Design Flow................._r,0..................gallons per person per day. Total daily flow........ t' .___.._._....._..____gallons.
WSeptic Tank—Liquid capacity,10t.gallons Length,,................ Width................ Diameter................ Depth................
xDisposal Trench—No. .............L... Width............... Total Length.................... Total leaching area----._.._..........sq. ft.
Seepage Pit No.... ,__. Diameter...... �Vepth below inlet.................... Total leaching area-� Q qs-. ft.
Z Other Distribution box, (, 4 Dosing tank ( )
aPercolation 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--___-_________--______-
ODescription of Soil...................................... d. -,,&e........................................................................
U ---------------------------------------------------------------------------------------------------------------------------•-------....------------------------------------------..........-••---......
........................................................................................................................................................................................................
•
V 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 XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of ComplianceAbissued by the boa ealt , e-
y_Si •••-•---• . ... • �---` ----- ------------ -- -----------
DateApplication Approved BY----- �� "�" 7
�
i/bate
Application Disapproved for the following reasons__________________
.....................•-••----------•------------..----------------------------------•-........--------------------------------------------------•-• --•-.. .... ...........................
ate
PermitNo......................................................... Issued.. •. ... ••. ---- ..........
D e
y
No... ............
Fes. �....................»
THE COMMONWEALTH OF MASSACHUSETTS
BOARD H EA
..... ............. OF........
..
Appliratioo for Ropooa1 Norkii Tonotrurtion rumit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
l Pt Location Address + t nor Lot No. ...........................
F *T..s . .
P ... ...,.::atc.
k r f Owner P r e er
............... f , r Address f .....................
............... ..... ....,.... ......... . ..................... ...'....... ........... .r,......... ...................._...........
r I stal g Address
t.. ✓dam
Type of Building ���`'�`` zs��� � Size Lot.../(4 ��.....Sq. feet
U DwellingNo. of Bedrooms............... ........ .Ex Expansion ttic— •-•••••.••-...•-.. p ( ) G rbage Grinder ( )
aOther—Type of Building ............................ No. of persons........... _.:`.!....... Showers ' Cafeteria ( )
dOther fixtu� g •--•---------------------------•-•--------------•--.----------------------------------------- -'�a --------- .........................
WDesign Flow..................4...:j:'._.___ .�, .gallons per person per day. Total daily flow........ :_::_::.•..................-....gallons.
Septic Tank—Liquid capacity}." -"�-gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—,No .................. Width. Total Length.................... Total leaching area _ ,c sq. ft.
Seepage Pit No... a� �(':_-.. Diameter.. <_A..6.._ Depth below inlet.................... Total leaching area.e, q. ft.
Z Other Distribution box ( -) Dosing tank ( )
aPercolation Test Results Performed bv-......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit...:................ Depth to ground water------------------------
;3, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....................---.
Q i 3
....................................................................................
` xaO Description of Soil------------------------------------x -• -- ----- ---•--•--•---- .........................................
....................
U ---•--------•----•••--•-•-•----•-•-------••------•.....-------••--•----•-••••......-•-•--•-••--.------•••-•-•-•-•...-•-------••••---------------------------------------------------------------------•-
W
VNature 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 bee issued by the�boWd:-of lealth: f °
r
S ram." "{; r-t
Date
Application Approved BY " -•--. " ---••-•.. ....... ------- ----------- --- -
---..-.-.
Date
Application Disapproved for the following reasons:................................................................................................................
-----------------------------•--......----------------------.......------------........------•...........I.•--•••-•-••-----------•-•-••-•-•••••••-•••-•----•••-•--••-•-•-------•••---------•-•--.........
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
...........OF......... .:.:.:.........:.........:....... ....................................
(9rrtifirate of Toutphaurr
T I CE FY hat the Individual Sewage Disposal System constructed ) or Repaired ( )
...
by '
...............
---•- - -- .................--- ...............................................................
has been installed in ...accordance with the provisions of ticle.X gf The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated.---------)........L—Y-.12sr5�..
THE ISSUANCE OFT IS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION- SA A TTO .
DATE...................... ......-- f-- .......... Inspector.--• :.._.......... ----. ................---...........--•---
( t
THE COMMONWEALTH OF MASSACHUSETTS Ayd
BOARD CW HEALT t
a
No.......... .. .......
FEE .................
ro o ntrttionrrutit
Permiss' herebyranted. (� r....... .. .....
g ...........................................•..-•----
to Cons orair ) iyjndl�idu Sew Dtsposal Sy��
at No.. ......... ..,... ,._-ems-... .... c ........'.................... ......................'
...
reet E fi
as shown on the application for Disposal Works Construction Pe lit,No.-. Dated.-...:" `
r �. ---------- -------•I
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1
t Board of llcilth
DATE...:.:: ....... :.... ;
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. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS' - -