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HomeMy WebLinkAbout0034 FORTES WAY - Health f-0 Itle"'L bg)(200 209( CutLess File Folders 48420 Tops-Products.com/Pendaflex MADE IN USA 30%PCF P4 J No.. •o ��d Fps..- ............... > THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _7 WU...-._....0F..... / /��. Tt K�-------------•--- App iratinn for Bi-gpmal orkii Tomitrnrtion ranfit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal 1,)qSystem at: � �/tjB , Q.. .T,�5..... ✓ .y...... ._ ................................................... Location- Location-Address ; or t No. .....�.�IY V..:2� N:ra^l------------------------------------ Igo...... Owner Address ' W ....... y EOCn..... .- . A............�� 1�...J ............. i Installer Address f Type of Building '—� _d Size Lot 2. Z ¢......Sq. feet 0-4 Dwelling—No.of Bedrooms___.._...___..........................Expansion Attic ( ) Garbage Grinder ) P4 Other—Type 'of Building ........:................... No. of persons---------------------------- Showers Cafeteria ( ) G4 /, .................................. g P-� --------------------------------- ------------------------------------------------------------- Design fixtures ................ ------ --- - W Design Flow.... ......_._ per day. Total daily flow................�2..G...............gallons. WSeptic Tank�Liquid capacity_AW-gallons Length 8' '... Width_e..? - Diameter___._................ Depth_.. x Disposal Trench—No. .................... Width....................Total Length.................... Total leaching area....................sq. ft. Seepage Pit NO-------L............ Diameter__/4.fT____ Depth below inlet___ --_. Total leaching area...Zgg�7....sq: ft. z Other Distribution box (,! ) Dosing.tank ( ) ~' Percolation Test Results Performed by-_.-:_X•----- ........�.m_....__..„.................. Date...1��/.�a�......_..... a Test Pit No. 1----L_Z__minutes per inch Depth of Test Pit___ �f..... Depth to ground water________________________ Test Pit No. 2................min es per inch D of Test Pit-------------------- Depth to gr and ater�:.______._._.._______ Description of Soil... ................. x ..'--.-Q.....V poi c. ---••-•-------•---------------•------------------------------------------ W ------------- ----------- -ill - ram..... -----e-1.7 ------------------------------................................................. UNature 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'TTL y g g p y 5 of the State Sanitary Code—The undersigned further agrees not to_ lace the system in operation until a Certificate of Compliance has bee i ued board f health. Sign l .. �Y ...__ ------•----- Date Application Approved By....... ..vim -- --•• .._.... . Date Application Disapproved for the following reasons------------------------------------------ ---------------------------------------------------------------------- --------------•--------------------........----------•-•-•------..__...._....----------•---•---.----•--- ----------------------------------------------------------------------------------------- Date Permit No.................... .f-'------------------ Issued.....- } De f / . N0:.7 . "_r Fn$........................... THE COMMONWEALTH OF MASSACHUSETTS t BOARD OF HEALTH - 1. JSh-O � . OF........... ..Z.r 73 LX f. Appliration for Dhipati al Work.5 Tuni3trurtion ranat Application is hereby made for a Permit to Construct (,\) or Repair ( ) an Individual Sewage Disposal System at: ............/ o .T...... .... ...S1�1 -y-...-----•------------------ ...............�_...."---5--- ----....------------...--......------..... Location-Ad Tess or Lot No. �> O ner Address i a = .7, 1 `--.........� .2&Z6- 'ATE- '4 ...1Y 411�! TsT.........._. .. Installer Address Q Type of Building Size Lot..210".... _.�..S(,'f t Dwelling—No. of Bedrooms............. ...........................Expansion Attic ( ) Garbage Grinder .) `4 Other—T e of Building No. of persons............................ Showers — Cafeteria a' Other fixtures ................................ e, ------------------------- --- --------•------------ r,..W Design Flow._._....� lJ.........................gallons per nprc n-per day. Total daily flow--------.-_--_✓�-3_h................gallons. y Septic Tank Liquid capacity/Q�ll.gallons LengthE .' .��_ Width_ _a6.. Diameter_.............. Depth_.. .-.���.�" Wf x�<� Disposal Trench—No.:................... Width.................... Total Length.................... Total leaching area.................... ft. Seepage Pit No------/.............. Diameter_,l0F,Fr:... Depth below inlet...4� .... Total leaching area..j-0.7.....sq. ft. z Other Distribution box.OC) Dosing t k ( ) a Percolation Test Results Performed by------X.-. ..__ .... f�_'__ :....................... Date......%7 1.°I-----___. a Test Pit No. 1.41....minutes per in5h Depth of Test Depth to ground water---.....-- ......... (i Test Pit No. 2................minutA er ' t----- ......_ Depth to rou d w er....�___...._..._____. o ----------------------------•-•-----•.4*­.�04------I�... ....................... ��'t Description of Soil...:. _.".�.�............ �ll!..� 'J'� .. ............••--•-------•-----------------•------•- x4 .......... Jr>13_V c c, ----------------------------------------------------------------------------------.----------------------••-•--------- U Nature of Repairs or Alterations—Answer when applicable..................................:............................................................ S ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the'aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TTLE, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Cenificate of Compliance has been i(Sal by t bops4 of healt . g ;'= / / } r....+� .--: ate Application Approved BY--------- �----------- ...--•-•-------------- - t & 1A- -.7-�. Date Application Disapproved for the following reasons---------------------------------------------------------------•-------------•------------------------...._...._ .---------•---------•---------------------------------------••-------------------•---•-----------•------------•--------•----------•-------•------•-----------------------•---------•-------------------- Date PermitNo......................................................... Issued...................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH • ....... ......OF.................................................................................... THI 0 #CIY4) ha the Individual Sewage Disposal System constructed ( ) or Repairedby.......... C ... . . --.0'X �,. has been,,installed in accordance with tlwisions of T 5 of�'T,i� tate Sanitary C e as escribed in the application for Disposal Works Construction Permit No__________________G/_.....��.... dated----- _.`_h- �f_.-.___.... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUN�CO N SATISFACTORY. DATE................... pector----..........` ..... ..... n �em _THE COMMO,.NWEALTH OF MASSACHUSETTS yk 07f . CC"" " BOARD F HEALTH 7� No......................... f FE ..................... �0�la�k� � �tr�Uan rrntt Permissi n �a''Fiere y - ant d .......................�; I... �/ q A4V .. ....to Constru��C��e b` divi�al S at No...•---•-----•-. .---•-- ---•-•-------------------------------------------•---..-..- . -------� -------------- i ...................... Street /� as shown on the application for Disposal N�'orks Construction PermAi� .._.._...._ a e _ -tJ.--I------- �.._...... - Board of Health DATE................................................................................ r, FORM 1255 HOBBS & WARREN. INC., PUBLISHERS 9' r $ 3` f"�.�,I�':­,�-1�".,�-,''­;�'­-,-,-,,i,1,,k.,_;:'Zri�1-�",.1,,��-,.�1I'j�I,,-j`;_�,���A.gl,�,",,- :. 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