HomeMy WebLinkAbout0041 BATES STREET - Health (2) ICY1
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KEEPING YOU ORGANi7F-n
No. 10334
2-153L
MADE IN USA
GET OMAN=AT SMM,CQM
y03 V-11,
CAT I " S W GE EIMIT NO.
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VILLAGE
I4I -109
INS Ll R°S ME 8 A'DDRESS
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P-,O-f,44�t Ad k
OR OWNER
DATE PERMIT IS.SUID
DATE COMPLIANCE ISSUED,
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
....... ......._ ....................OF......................................................................................... }�
Aliptirtafiva� fur Uhip ti al arks Tonutrurtion ;trout
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: . ...........
-•--t No
l�h 7_�-` Lo o res or Lot No.
n i ddres
W =: - ................................. ........ .. ... .:...
�., ---- .
Installer Address
d Type of Building Size Lot---- feet
U Dwelling�No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' 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 ( )
'-� Percolation 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........................
..- ----�
0 Description of Soil.. .............•-•--------------------•--------------------------------------------------------------------•-----•---------......--•-------
M
V -----------------------------------
•--..-.---------------------------------------------------
•-------------------------------------------------------------------------------x --------------------------------------------------------------------------------------•---------•------••---. ..._------ -- -- --- j d---------------
U Nature of R rs or Alte ations And e when. licable,�. _______________________ -.
--- -- -------•. .�aG� . -- . ------------------------------------------------------------•..-•--•.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ispuyril by t e ebord o alth.
Signed �........-•--•--• - -.....................
Date
Application Approved BY — -a..- ....-----•--
Date
Application Disapproved for the following reasons-----------------------------••------•--•------------------------------------•---•-----------•-----............_
-----•-------•--------------------------••-•---------------....-•---._......--------------•--------•---•..--------...--•------------------------....------------------------------------------....--•---
Date
PermitNo......................................................... Issued....................................................... 1
f. Date
` THE COMMONWEALTH oF MAssAo*ussrrs
( U����� ��K� ���� HEALTH
�
~~�~" ." ^�� �~" " .��" ^�~ " " " �
� ................. ........................OF-----------_—__'---�_______
for ° �
Applir« tmoo� ��� Dispn�� K� Works �onstrurtiouuramit
� Application is hereby made for u Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at:
"` ^= �"
.. .... .......... ...................................
Z ...7....�Zn&.qe.'................................ 4 .... ..W.. ...
IV Installer Address
Type of Building Size Lot............. feet
Dwelling401�o ,f Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( )
Other—Typeof Building ............................ No. of persons—.___--__-- Sbm,czo ( ) -- Cafeteria ( )
� Other6�o�o
^� .^ —'..—'�--_----------..----_-..-------.--_---------------_-------------
Design Flow.............................................gallons per person per dun Total daily 8ow--.----------------' .
Septic Tank—Liquid ............gallons Length_............. Width................ Diameter—.---- Depth................
Disposal Trench--No. .................... Width.................... TotalLength..................... Total leaching area....................sq. f t.
Seepage Pit No..................... Diaoeter---__-' Depth-below inlet.................... Total area..................sq. f t.
Z Other Distribution box ( ) Dosing tank
~~ Percolation Test Results Performed bv'—_—.---..---'__'__'---.�-_'_'_-. Duc�—'__--__--__--'—
Teu P� No l per��h Depth of Tea Pit.................... Depth to ground water........................
Test Pit No. per inch Depth of Test Depth to ground water..........................
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0 Description of
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