HomeMy WebLinkAbout0340 NORTH BAY ROAD - Health qo
L 0 CAT ION S E A G E PE RgIT 130.
VILLAGE
II1STA ER'S DE lk ADDRESS
0 U I L D E 0 OR OOIDER
o
DATE PERIAIT ISSUED
DAT E COMPLIANCE ISSUED
I
a
p 13ok
No. lh ... FRs.......�1�.................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ® HEA TH
... O F
Appliration for Uhipviial Workii Towitrnrtinn ramit
Application is hereby made for a Permit to Construct ( ) or Re it ( �n ndivi swage Disposal
System at:
v
n Location Address r Lot No.
--�4tv.�t.... '1. `. °•-------•- -•--•-------•----------------- a.l'= �1__ / oJ4l�. .............
I - .......
caner - Address
a •... . ..... --•-----------------------------
nstaller Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ✓j Garbage Grinder ( )
`4 Other—T e of Building ............................ No. of persons............................ Showers — Cafeteria
Other fixtures ..............•----------------- ... .
W Design Flow........ 5 ...........................gallons per person per day. Total daily flow------------
7_12-0....................
WSeptic Tank+Liquid capacity,.....`'.._.gallons Length................ Width----_......_.... Diameter___-___________- Depth.............
x Disposal Trench—No..................... Wid .................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..._____.�__.... Diameter-__6------------- Depth below inlet.........?......... Total leaching area...I/Q..2..sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-------------------------------------------------------------------------- Date........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit___-_____.___...___. Depth to ground water_-___________-_-__---_--
G%, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
--•------------ -------------- --------•--------------
O Description of Soil l
---------------- ------- I �-
W -------------------------- ------------------------------------------------------------------------------------------------ - ------- ....................... ---=------ ---------------------
UNature of Repairs or Alterations - Ans er wh appl' ble.__.____"�-.___ _ __ '.7 _ :___ __ 7 .�� _............
�-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of LI`: _.i' y g g p< y of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been is he boarVof alth.
.��
D e
Application Approved By......... Y.� ...... ••. -• = Gi' -�-----.--•-.--.----- � �- � =---....
Date
Application Disapproved for the following reasons----------------------------------------------------•------------------------------------------------------•-•---
....................•-•------------•------•-••-•---------•--•---••-------••-------------------------•------•--•-••••-•-••--------•-----••-•-••----•------•-----••-------••----------••-----------------
Permit No......................................................... Issued----..G--..... -�.
---•--Date_..:...
Date
No ............... Fps. ........�....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HE TH
& ......OF........... .... . ...... '--..._........_........
Appliration for Uiipnial Warkii Tatuitrurtinn 1hrutit
Application is hereby made for a Permit to Construct ( ) or Re it ( 'ran ndividual Sewage Disposal
System at:
.......................................... .............................. ........................... ............................
Loc do Address t No.
caftg
Owner Address
W
Installer Address
d Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( Garbage Grinder ( )
Other—Type T e of Building No. of persons................. ,_:_: Showers
t� YP g ---------------------------- P --- - ( ) — Cafeteria ( )
Q' Other fixtures .--•-------------------.......................................
Q •---....--•-•--------••----
7-0
W Design Flow_ __._�:�A..............:..............g lions per person per day, Total daily fl ow-.._...___._._._.___._.__...................gallons.
a
WSeptic Tank Liquid capacitlr.°`'.gallons Length................:;Width................ Diameter................ Depth................
x Disposal Trench—No..................... Wid ................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------- ------ Diameter....0............ Depth below inlet........k........ Total leaching area... h ..sq. ft.
Z Other Distribution box ( ) I I Dosing tank ( )
Percolation Test Results Performed by........................................................................... Date........................................
a
Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water........................
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Description of Soil .....- 11. '=`�'--- ....
x
.
l = r
---------------------------------------------------------------------------------------------------------------------------- --
------ ---------------------
U Nature of Repairs or Alterations er wh appl' _le_.-..."" ___ __ _ _____-
�E
' -� d� = � / 'P
Agreement
J
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL 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 been_is ue,d by e boar of h-alth.
igned .... •--- .-- =`"� ,fl ¢-
Application Approved By...... �'r-tom '' ._..;_.... t`ry D
Date
Application Disapproved for the following reasons:_...__
............•... --.....-----•...-•.................................... ••••----•-•---
-----------------------------•---•--•---......_......._...------••••. .....----•••-•---•----••-•--•---•---•••-------•-••-•-----••-•----•-•••---•-•---------------------•••--•--•--------------•-----••-
,, r� Date
Permit No...................................
...................... Issued-•--.t..................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD (? HEALTH
................ ..�--l-rJ7...oF........... . ......... ............. ..._...
i� �`..... . �.......
Tnrtifiratr of ToutpliFanrr
THIS I 0 CE F-Y; T-hah�e Individual Sewage Disposal System constructed ( ) or Repaired
by ....-- ............. f .........................
G!1!/s. pl !!?�!..... -- .* � ........ /_® s ler • -- /_?._.. ... f ..
has been installed in accordance with the provisions of T /1' j he State Sanitary Code as des bed in the
�_ ."' ,
application for Disposal Works Construction Permit No. ____ ---_-_-_--. dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WIC L FUNCTION SATISFACTORY: "
DATE.......... � ............................................................. Inspector....
..................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA T
` 1 .. ... Old
OF.-....... ..:............ .. �..............,.-,... --. -.--
NOoI7 o......................... FEE......::.
Dispno al k u , trudiott rruti#
Per is hereby granted ... --• -• -•-•-- ........
to Construct ( ) or pair ( an I idual S ra e Dis S t e J
Nw
Street
as shown on the application for Disposal Works Construction it o.... .:. ...... ted......_. �•_`. .�........
/1 �� Board c Health
DATE...... _ 7'_ •-••-•---------•--•---------=--••-•--•-
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS -