HomeMy WebLinkAbout0199 HAMDEN CIRCLE - Health � �► ,,-
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A ION SEWAGE PERId-T NO.
LO C T
VILLAGE
171 / S
INSTALL R S NAME & ADDRESS <<�
B U I'L D E R OR OWNER
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DATE PERMIT ISSUED _ 2f
DATE : COMPLIANCE ISSUED _
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HE-ALT
(�V.. ......O F.............R..
Appliratiun for Uiipuual Works Tonstrurtiun ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Y
S stem at..... ..... 0 .................
Lo tion•A ess �- or Lot No.
O er Address4
Installer
� Address �
--� Type of Building Size Lot---- feet
Dwelling—No. of Bedrooms.......... ____________________________Expansion Attic ( ) Garbage Grinder ( )
'4 Other—T e of Building No. of ersons._________
a YP g P ----------- Showers ( ) — Cafeteria ( )
Other fixtur s. •- --------•--•.•---•------..------------------•-----------.-_._._..-••••- --
------------------ - - -
W Design Flow_________________ _ ___ _______________gallons per person per day. Total daily flow______._.____________ _ gallons.
W - Septic Tank—Liquid capacity gallons Length_______ __..... Width._ Diameter________________ Depth................
x Disposal Trench—No_____________________ Width_ _�!__._._.__.__ Tot Length....... ./-__ Total leaching area....................sq. ft.
Seepage Pit No-----------/-_______ Diameter._._.._.___.._. Depth below inlet__ ____..... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ,�/
a Percolation Test Results Performed by...... t _•_L7.:. _ ______ Date......ll/:-.1Y
'Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water_____----------------
rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground waterpq:f�d -
a -- -- ---- , •• - _••• • _••-_� -- ------------ - /--- -- ' ..
O Description of Soil _..._
x
(� ..._ ...........................................
- -
W ------•----•------------------•----- ..---•---------------•---•-••------•---•••-•••--•--••--•••-••••••-----•-----..._....•------:-••-••---••••--•---•--•-••--••-•-----_____••. ...............
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 TITL U 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been sued by the board % -lth.
Sign.d-•-•• ••••-- �
Dat
Application Approved BY ...`. • -------------•--.._......
e-7
Date
Application Disapproved for the following reasons:_
-•---•--•-•--•-•-----------------••--••---•--••••------•---------•--••-------•---•--•---. .....-•-----
•--•-----.......••---------•----------------•--••----•-----•------------•-•-------....--•-•-•------•-•-----....••••-••••••••••••-•-•-•--••-----•••-------•••••••-----•••-••-•-----•-----•••-•••-••----
/' Date
Permit No...................................................... Issued-f�O..` --- -------------------
• Date
No..� Jam..+ FEic ._.--. �..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH i
£ u . .......OF....... f:.;... ?.:... .. .: .....
Appliration for Bispao al Works Tonstratrtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
............ 5 Y. 9 .✓? .*?.. ........ ......._ `... ��..r ......
f Location -Address f - or Lot No �r
Owner
Address
ar t 1 < ..................... ------...... ? ' ..f�,r' ? , +`.!�?................................
Installer Address
Type of Building Size Lot... feet
U Dwelling—No. of Bedrooms.._._...::
, Expansion Attic
Garbage Grinder.................. ( )
aOther—Type of Building ............................ No. of persons.......... ............. Showers ( ) — Cafeteria ( )
Otherfixtures,,....................................................................................................................................................
W Design Flow.................. ..., __ _.gallons per person per day. Total daily flow.........._.____ t ..............gallons.
iX Septic Tank—Liquid capacity=�;.gallons Length...... Width. . Diameter................ Depth................
,,W �• -Disposal Trench No ................... Width Toff Length_-_...�. , 1 Total leachingarea....................s ft.
Seepage Pit No ..;. :....... Diameter .... _...._ Depth below inlet. 4{ Total leaching area..................sq. ft.
Z Other'Distribution box Dosing
�.-task ��, � � +�
Percolation Test Results Performed by...... ,- �.:s�:' ' ..,_ . Date.....
Test Pit No. 1_._... .,minutes per inch Depth of Test Pit.................... Depth to ground water.......................
44 ';Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water ' f
R+ . ---------------------
.._O Description of Soil_____________.:___._ -•-- >
V -----------•-•.................... ---------------------------------------------------
-...
.
------------
W
UNature of Repairs or Alterations—Answer when applicable................................................................................................
---------------------------..............................................----------•-----•-----•------••----------------------------•----------------------------------------------••-----......••••--
Agreement: ,t
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'antil a Certificate of Compliance has been,ytssued by the board of 1iealth
Sigd ? . .......t' " --------------------------------
J Date
Application Approved B
Application Disapproved for the following reasons-..................-------------•------------------------------...•----.,--- •---------- Date....................................
--••--•---------••••-•--•----•••-•-••••-••••••--•-•-•••••---......••--••-••--••-----....---•----...•-----..............................................................
Date
PermitNo......................................................... Issued.........................................................
Date.j,
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
(9rdifirtttr of TontpliFanrr _
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed'(- ")"or Repaired ( )
by............................
"
,r Installers'
at-•---, ....------ / ------------ _t .:._ ...-•-------------•-•--------•
has been installed in accordance.with the provisions T' + ,1- of The State Sanitary Code as described in the
application for Disposal Works Construction Permit ::_ LF�. ..................... date/,O_'":;!..F.._---- -7............... -
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ 'Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
�))f
BOARD OF
HEALTH
7 ..... .�� ...........OF.. ................................ ,
O....................•.... !, FEE..........
works ��ans#r�tr# rrn rrtni r
Permission is hereby,,granted_.._.. .....?.. f " ......: .: ..... r."" ��" .3
to Construct ( ) r Repair ( ) an Individual Sewage Disposal Systems 5
:at No... l . .l.... �` {dam .. " ... .----------••......-•----......
�'~ Street - ••
as shown on the application for Disposal Works Construction Perm3 No -_ __. Daa�todp__--._...`1...........:
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS r "
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