HomeMy WebLinkAbout0162 MAIN STREET (OST.) - Health '1.620'a"'WStr`6k, .,;.,,: _
A 165 073
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LOCATION : 5EWQC,E PERMIT UO.
IMSTNLL.ER5IJWE ADDRESS
BUILDER 5 Q TIE ADDRESS
DACE PERMT ISSUED
DATE COMPLI &MCE ISSUED ;
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No....y�A...... ..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD JQF HEALTH
------------
. .................. ............ ----------------- ........
Appliration -for Uigpoiial Works Tonstrurtion Vrrmit
Application is hereby made for a Permit to Construct or Repair\ (�an Individual Sewage Disposal
System at: (7
C44"t 4.4
................................................................... .................................................................................................
L Address or Lot No.
.................
.......... .. .. .. ........................ ..................................................................................................
� ,owner Address
.......... ..e
............................ ................................................ ...................... ...........................................................................
Astaller Address
Type of Building Size Lot--_-----------------------Sq. feet
U
Dwelling—No. of Bedrooms------ ..................................Expansion Attic Garbage Grinder
Other—Type of Building ---------------------------- No. of persons---------------------------- Showers Cafeteria
P4Other fixtures ------------------------------------------------------ ------------------------------------------
Design Flow.............
W ...
.............................gallons per person per day. Total daily flow-----------------------------------Lr_,---gallons.
9 Septic Tank—Liquid capacity------------gallons Length................ Width....._...--.... Diameter_.-_-...-_-_--_ Depth':-__.--_.----.
Disposal Trench—No- -------------------- Width__.--_-_-_-____----_ Total Length--____-__-__----_--. Total leaching area----.---_._- .---_--sq. f I.
Seepage Pit No..................... Diameter........._.-__--_-_- Depth below inlet......___..._._.___. Total leaching area-_-------------ST It.
Other Distribution box Dosing tank
Percolation Test Results Performed by------- ------------------------------------------------------------------ Date----------------------------------------
Test, Pit No. I................minutes per inch Depth of Test Pit..............._.__. Depth to.ground water-_--------------------
f� Test.Pit No. 2................minutes per inch Depth of Test Pit___._..........._... Depth to ground water-_---._---_-__-._-_-----
......................... ---------------------------
---------------------------------------------------------------------------------------------
0 Description of Soil---- 0.(------- ....... ................................................._---------------------------------------------
U ------------------------------------- -------------------------------------- ................................................................. ........ .......................................
---------------___------------------------------------------------------------------------------------------ -----------6X.4--- ----------------------------
U Na re of Repairs or Altuations--Answer when applicable..-------------------
----------------- --------- --------------------------------------------------------------
------------------------- ---------------------------------------------------------
------------- ---------V
------------------Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article X1 of the State Sanitary Code— The undersigned further agrees notto place the system in
operation until a Certificate of.Compliance has be issued by the board of ealth.
�ee ?C/
------4 ..
Sign ........ --------ge_... .......a--- k-d-,----------------- "" - /6_1
Date
ApplicationApproved By---- A-----_----------------................................................. --------------------_....... ---------
Date
Application Disapproved for t e following reasons:......................................................................................................... ......
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Date
Permit No.----- ....................................... Issued/a/�-----A7.3...........................
Date
--------------------------:�-------------------------- --- -- -- - -
06
No...... ...... ............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.. ... .................OF. /.........................
Appliration -for MaVviial Works Tutuitrurtion Vrrmft
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at*
. .............................................. .................... ... .................................................................
Address or Lot No.
...................... .................................................................................................
Owner . Address
a .............
...................... r...... ........................... ......................&jr,:......!.....................................................
Astaller Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms-------?----------------------------------Expansion Attic Garbage Grinder
Other—Type of Building ------------------------_- No. of persons_.._......_........_._....._ Showers Cafeteria
PL4Other fixtures ---------------...................................... ---------------------------------------------------------------------------------------------
Design Flow----------------ro 34 ,1
W _......................gallons per person per day. Total daily flow--------------------------------------------gallons.
04 Septic Tank—Liquid capacity............gallons Length________________ Width..___........... Diameter_.__...._...__.. Depth-._----_-------
Disposal Trench—No- --------------------- Width___--___-_-____.---- Total Length.._............_._.. Total leaching area--------------------sq. f t.
Seepage Pit N:)--------------------- Diameter.................... Depth below inlet........_.._.._._... Total leaching area------- ----------scl. ft.
Z Other Distribution box Dosing tank
Percolation Test Results Per'fo.Tmed by------................................................................... Date----------------------------------------
Test Pit No. 1----------------minutes per inch Depth of Test Pit.._.._..........._.. Depth to ground water..--__------._--__.-._..
Li, Test Pit No. 2----------------minutesper inch Depth of Test Pit.................... Depth to'ground water.-.._.____--_.__-_---.
1-1-------------------------------------- ..........................................�:......................................................
0 Description-of ......!t... ........... -----------------------------------------------------------------------------------------
U ----------------------------------------------------------------------------- ........................................................................................................................
------------------------------------- ---------------------------------------------------------------------------- ------------- -------- -----------------------------
r when applicable------------ -
U Na re of Repairs�-----
ations--- 4Dswe ---------------C------
--- ----------
-- --- ----- .......................................-------------------------------------------
Agreement:
The undersigned agrees to install the aforedespribed 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 been issued by the board ot&Aiealth.
0'7 .
...... -----
....................if................. ----- Y"
7' , —Date
ApplicationApproved By---------- -!./................................................................................ ----------------------------------------
Date
Application Disapproved for t leffollowing reasons:...............................................................................................................
.................---------------------------------------------------------------------a............................................................... ..................................................
Date
Permit No------ ..................................... Issued .. .........................
Date
THII E,COMMONWEALTH OF MASSACHUSETTS I'me '01-
• BOARD OF HEALTH ,P.
.......................................... .........................
Tntifirate of Tompliaurr
r.
T,VW_IS TO-iJERTIFY, That the Individual Sewap Disposal I System constructed or Repaired (01;.-)
by............_�dp�k...........9---Z...).:.C__ ....................... APO,....................................................................................
.... --------------
nstaller
at----------------------------------------- ....................................................I-------------------------------------------------- .....................................................
has been installed in accordance with the provisions of Article XI of The State SanitarvY'Co;d�e�'�-'A's d' ie'scribed in the
application for Disposal Works Construction Permit No-------- ...................... dat d../6/!(2-4/Ty----------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION §ATISFACTORY.
..... ........I----------I...I------------------ Inspector... . ..........................................................................
DATE.................... _6
THE COMMONWEALTH OF MASSACHUSETTS
BOARD EALTH
..........OF.I.J................................. .......................ig................................................
No....
FEE__ . '_' ._.....
Mle. ........
Binvvfel Wvrkp Qlantitrurtion Prratit
Permissior is hereby granted............cz..............40- '
-c.. " .......*---------------------------------------------------------to Construct ( ) d n i,,pF Repair I vidMa gge D6 is oral System
.... stem
atNo/#'��'--"-'--------170_41ft. .......................................................................................................... ......................................
Street
as shown on the application for Disposal Works Construction Permit No..5/�t3........ D a t e d..
............... .............................T.. -------------- ..........................
5 rd of Health
t
DATE........ ........................................
-FORM 1255 HoBPS-& WARREN. INC.. PUBLISHERS
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