HomeMy WebLinkAbout0055 SEA STREET EXT - Health 55 Sea Street Extension ,
A - i
No.5.— FER2.....................
tioll- T THE COMMONWEALTH OF MASSACHUSETTS
Application is hereby made for a rmit to Construct or Repair an Individual >ewage Dispos
System aV
----- -- -------- -- - ------ - ----------
Im ea� a Z a AoLot No.
Address
�nstaller Address
Dwelli No. of Bedroom Expansion �,ttic Garbage Grinder
Other Type of Building -3---t_ - - o. of persons:�.......(ze-------------- Showers Cafeteria
..... .. ...... W
al
Seepage Pit No---------)*
Other Distribution box Dosing tank
-----'----'--''--------'--'--'—'-----------'--'—'-----------'-----------
Agrovnz,o,:
The undersigned agrees to install the aforcdcscribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Snot to place the stem in
operation until a Certificate of Complian a en issu of health.
Application Approved By-- ..... ........ ........ ...... .... ... .............. -----/
----------''--' ----'
0.5_4Y----- . ......................
THE COMMONWEALTH OF MASSACHUSETTS
EOARD OF HEALT
........OF.......... .... .... ,d-....... .........�--.'
Apptirtttinn -fear Biiipoiiat Workii C ontitrurtitttt Vrrn it
Application is hereby made for a ermit to Construct ) or Repair ( ) an Individual Sewage Disposal
System a
v ,
Loc o -Address (//" or Lot N.,
ac. ..... .....)./.......
vL'ner Address .Ar^" "
W f{
Installer Address
Q Type o uilding Size Lot____________________________Sq. feet
U Dwelling—No. of Bedrooms .._1_r_____.__ [________________Expansion ttic ( ) Garbage Grinder ( )
p�, Other-Type of Building . _ __4� o. of persons--------- ------------- Showers ( ) — Cafeteria ( )
dOther fixtures --� -- - -------•-•-------------------------------------------------------------------------------------------------------
Desi nFlow__ � allons person per day. Total daily flow...........
W g a� P P Y. y .-!"1...._�r........gallons.
WSeptic T tnk�-Liquid capacity allons Length---------------- Width................ Diameter_---..--------- Depth._.---_-__.-----
x Disposal Trench—No- ---------------_-- Width--------- _____ ! To al en'tki___________.. To a leaching area_._..._____..__...sq. ft.
> >Seepage Pit No.___--_ , ______ Diameter___ e be o r e �' _-__.___. ` otal leachin area.
------------ sq. ft.
1 ' ' --- g � 1
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date--------------------------------------..
Test Pit No: I................minutes per inch Depth of "lest Pit_--_-___-________-- Depth. to ground water------------------------
f4 Test Pit No. 2................minutes per inch Depth of Test Pit---................. Depth to ground water------------------------
04 ----------------_-------------------------_....................._............................................................ .
0 Description of Soil........................................ -•-•-- - ---------------------------------
x
W -----------•-••--•'- ------------------------------------------ ....... erg-----`--± "---- a
--------------------_------- ------------------------------------------ ------------------------------------------------------------------------------------------------ ........................
V Nature of Repairs or Alterations—Answer when applicable!.---------------------------------------------------------------------------------------------
I'Ili
--•--- -- -�----------------------------------•-----•-•----•-------------------------------------------
Agreement:
The undersigned agrees to install the aforedtescribed Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State Sanitary-l de The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the,board of health.
.. ,, - ,•.
''Si ned - -- ` ... _N •------ •------- ------•-•--•--------•-- ......--- .....
�� Date r'r
C
Application Approved By .• >_. !rr
- = - e
Application Disapproved for the following reasons--------------------------•-•-----•- •---._...•------------••.
ft
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF.MASSACHUSETTS.
BOARD OF HEALTH
1771' 1.............OF.......f....... .............................................
&rrtif irttte of Tontlititturr
IS STO CEPTIF4;1171hat the Andivitlual Sewage Disposal System constructed ( ) or Repaired ( )
by .. 1.: -t __ :...; f - ....................
fInstaller
at �f1 d? f`. - r.. _ - ft �_ _
r �, t f f
has been installed in accordance with thFJ provisions of Ar cle Xf of The State Sanitary Code s des'cri ed in the
application for Disposal Works Construction Permit No.--_____. °" dated..:._ --- __.:
PP P � .......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE C ST'RU D AS U NTEE THAT THE
SYSTEM IL FUNCT N SATISFACTORY.
DATE __ Inspecto"r (PCs........
THE COMMONWEALTH OF MASSACHUSETTS!,
#! BOARD OF HEALTH .
r !'L .. .. 1..... ."O F........ G�K+!1e !'t
No......`.................. FEE---a =----------------
Di Venal Workii-r( onithirtn rrmit
Permission s,•hereby grante � ,f `... ..`--- ---- _--- _
to Constr act ( -')' o �?RepIir (,� �1`rn..IndYvidual .S,, age Disposal System
at No._i-__ fa ! t�__ .- / .._ )'r�l_s,� .- -Yt........................................
mac- s�7 c !7� .: ,f ..................
--------- -----.-•----.
}' .a'- •�. -------- �/' street !•� t. / •�,("
as shown on the application for Disposal Works Construction Pe�it Now__-.____-_:_f... Dated... ,/------ ,/ I
f' Board of Health
DATE--------------------------------------------------------------------------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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