HomeMy WebLinkAbout0022 NATHANS WAY - Health � _ e���\le , 12z- dry f-- �
LOCATION! ' EW&C�E "RMIT UO.
VILLAGE '.
IWST LLER 5 W&PRE ADDRESS
7
13U1 DER 5 IJ�,� E � QD0R SS
D47E PER"VT ISSUED
DATE COMPLI &MCE ISSUE® :
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No...._.. D..... �. K Fi$..AA......�—
THE COMMONWEALTH OF MASSACHUSETTS
�. BOARD O 7EA
T
lfLu .........OF..... .,.._ .. .: ....... .. . - ................
Appliratiun -fur Maposal Workii Tattfitrurtiutt Prrmit
Application is hereby made for a Pe�rrlit tp/C truct� a 0�or epair ( . ) an Individual Sewage Disposal
Syst at Ctt JJ�e- q tr�r�Jd/ f
•; f�J ? %ems , ............... . •-•---••------ L _ =
cation- ss or Lot No.
"' ------
•-••--------------- •-----------
_ O e �� Address
----•-••--.f_f_ .._.. � 6.s.��....................... ................:. ....._:-`-0-
Ins aller Address
Q Type of Building Size Lot/r._ J. ----Sq. feet
Dwelling—No. of Bedrooms...........���............................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures ..__ '' `...._ _____
Q ------------------------------• ---------------------------
-------------------W Design Flow........ _��______________________gallons per person per day. Total daily flow................�._C_��___....._...gallons.
WSeptic Tank—Liquid capaciWe--e allons Length................Width................ Diameter---------------- Depth-_-_-_-.--...
x Disposal Trench—No_ Wid ................... Tot ,.___.. Total 1 �chin�ca.___._...__...sq. ft.
Seepage Pit No.J Di t _ _ � ea------------------sq. ft.
z Other Distribution box ( ) Dosing tank ( ) --Z�6 —7,/
aPercolation Test Results Performed by........................................................... ... Date........................................
Test Pit No. 1................minutes per inch Depth of "Pest Pit.................... Depth to ground water_..---.---_--_-._-.-----
�14 Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water-----.---_---_-.--_-_---
........
d
a J ry ��r �z- .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 Article NI of the. State Sanitary Code— The undersigned further agrees not to place the system i
operation until a Certificate of Compliance has b en issued by the bo rd� ealth.
Sign `�� '--- -�--- •. `.
D to
Application Approved By....... =- --- ���'u . ^--------------- ---------�..°Z�' 7G------
Date
Application Disapproved for the following reasons:............................ .•--•--•-------......_..........-•-•-•---------------•---•---•----•........•-•---
•---••--••-•---•••-•-----------------•-----------------------------------•-----••------•-•-•--•----------------------------•----•--•---------------------------••--------•--•----=-----------=•..------
Date
PermitNo......................................................... Issued........................................................
Date
c _
Ficii
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH ,
A.VVIiration -for RiiV oal Morks Tonotrurtion Vrrmit
Application is hereby made for a Pe;i t�/Co�l�truct ( ) or epair ( ) an Individual Sewage Disposal
Sys at ) __-? µ�.�jj �-- -- j
-------=�f /-�,rs /�-i,-:-•r.— /�t�.! .� ..:.: ! ---------•-------•------------------
-•-
• Address / or Lot No.
_ice/,>• Z�Location 11 /i!/�r / "%,Z-'r7
. ............•.................. ...
Owner/ Address /
r �
a •.........•-�-- ..... ..................... - ---------------------------==/---......:...:........_.......:-•�....
Installer Address
Q Type of Building Size Lot.� .---------.--------Sq. feet
U Dwelling—No. of Bedrooms....-v----- '------------ .--- Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures -' ------.---?--e.SZ----•--•--•----------------------
Q
w Design Flow..--------f .j�2.....................gallons per person per day. Total daily flow----------_---_- -----------gallons.
tx Septic Tank—Liquid capacitdlZ&Qgallons Length---------------- Width.........------- Diameter....___-_--.- Depth..-_-----------
Disposal Trench—No. ..................... Widtly' -------------- Total��ngth.................... Total le Ching ca-------------------- ft.
Seepage Pit No... l� �i ter � 't ... Depth%belo��✓itflei����----- "ot�l lac iI Ig area._.__..._.......sq. it.
Z Other Distribution box ( ) Dosing tank ( ) -� 6 —76
~' Percolation Test Results Performed by........................................................... -. Date-----.-.-.-----------.-----------------.
Test Pit No. 1................minutes per inch Depth of "Pest Pit...----..---.-----.- Depth to ground water_.--------..........�14 Test Pit No. 2................minutes per inch Depth of Test Pit..--------..--.--_- Depth to ground water.......-.--..-..--.-.._.
..�•.3 . -- ... r
Description of Soil--- --------(� �--------- --- 'rf -�
x
-j.....(. --------------------•--------------------------------------------------------------
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 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 boo d o j health.
.....:-G __�'/�7 _
Application Approved By---•• f '- %��'�'1-_L L�. -----•---- /-�-ZL
Date
Application Disapproved for the following reasons:--••--••---------••----.....-•--•--•-------------------------------------------------------------•...........•--
I
--.......--•--------------------•----------------------------........-------------•----.........------...............----..............---••-------..•-•---•----------------------------------------•---
Date
PermitNo......................................................... Issued...................... .................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
. � BOARD �OF HEALT���
OF
%:.Jrrtifirate of f"ompliattrr
THIS IS—TO CERTIFY, That/the Individual Sewage Disposal System constructed (GG-) o�ired ( )
by.......... r/ ���✓
Installer
----------
at-------- ..................................... /// ! C!1
has been installed in accordance with the provisions of Arti I of The State Sanitary Co e as described in the
application for Disposal Works Construction Permit No.--.�...--..--..- !=� .......... dated.....-. .'. -.�.. ..............
THE ISSUANCE OF THIS CERTIRCATE SHALE. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector -- ---------------- -----------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF, HEALTH
No.......... -••••-----•--- /` FEE-------- --------------
Di Vosal Works �onotr�trtiott- drrtriit
Permission is'h 'by ranted............... �`':='f ............... rf ✓' '' ..
...........................................
to Construct ( or Repairer( ) a Individual Se ra e Disposal-Sys
at No. - = k - -6 - -q.,�rt /� --= ----------------
Street
as shown on the application for Disposal Works Construction Prmit N r - Dated.....�.'�.f/
Board of Health
DATE................--..................................-------------------......... f`
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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