HomeMy WebLinkAbout0105 PINE LANE - Health-r .,�--
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LOCATION SEWAGE PERMIT NO.
VILLAGE
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INSTA LLER'S NAME i ADDRESS
e U I L D E R OR DOWNER
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DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
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No.... ...
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® F HEALTH
.... .........OF...... 0..re)... ..........................
, ppliratiou for BhipasFal Workii Tomitrurtinat tirrmit
'Application is hereby made for a Permit to Construct ( ) or Repair (�n Individual Sewage Disposal
System at•/eq � -- C-
-. .....................
Lo ti n-Add s or Lot No.
.............�� .. :.. c-- -.... ---- ..
.__ ........
pW ddress
a ...........`+F- .......... ........> ----------------------------- --------- ---J----- �.----------------
Installer 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 ( )
Q' Other fixtures ......................................................
--•----------•------- -•------------------------------------•-• `
W Design Flow............................................gallons per person per day. Total daily flow............................................
WSeptic Tank—'Liquid capacity............gallons Length................ Width---------------- Diameter----............ Depth................
Disposal Trench—' No. ..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
. Depth below inlet..............:..... Total leaching area..•......••.•_....s ft.
� Seepage Pit No--------------------- Diameter.................... p g q.
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.......t..........._._ Depth to ground water........................
-...............................-----------------------------------;--••••••............-•••----....-•••-...•-•---•---•-••=----•---•----•--•••------•-
ODescription of Soil-------------------=----- -------.........................................................................................
,
----------------------------•----------- ------------------------------------------------------------------------------------- •-•---......•-•-•-/----------'--- ----------------,.
U Nature of R pairs or Alterations—Answer when applicable..%. v.----. _- - Z......: �,, �_ ...:
Agreeme'n�
T;fie undersigned agrees to install;the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIU 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has,been i1spied bypthe board of h h.
Sig ---- �%�' Plr / f�=
ate
ApplicationApproved BY . ... ........................................................................ ... -
Date
Application Disap ve r t following reasons------------------•-----•-----------------------...-•------------------- ------------------•-• -••-••--••••--•••-
.............................. . .... -----------------------•------------------------•-------------------------------
Date
PermitNo. ---------- Issued---------------------------------------
Date
1�
No.._. �....�....�....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD - . HEALTH
. .............OF....... .. ... ... :_�..1-..............................
Appliraation for Disposal Works Toaastrurtion Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ran Individual Sewage Disposal
System at: `/J1 f �3 (jI (�1
...........................................SrY . ............... ......TR......... ......................................... .+_ h........_......_._.._................._
...... .
Lo ' n-Add s or Lot No.
.. �.� .... ° . ..t.�.................................. ........................... ..---------------..........._................_....
-- . -
Ow ddress
w ----------------------•---- _ -
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms________________________________ _Expansion Attic ( ) Garbage Grinder ( )
Other—Type T e of Building No. of ersons____________________________ Showers — Cafeteria
cal YP g ---------------•--...------- P ( ) ( )
Pa 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........................................
14
Test Pit No. I................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...............................................................................:.-•-•-----------------•------------------------------------------------•--••-----_--•---
x
W ••••-•-•---•-------• ••-•--------•-----•-------••------••••---------••--•------------••---•••••••••---•-•-••--••---•••---•-••-••---•-•••----•-•-••• ---------------------------------•-• _.._..
UNature of R,pairs or Alterations—Answer when a plicable._____:a _ ...... ......... ......
AgreemenP—
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to Flace the system in
operation until a Certificate of Compliance has been is ied the board of h h.
. f
Signed r-----------------
ApplicationApproved By .. .-....................................................................................
Date
Application Disap ove r t following reasons---------------------------------------------------------------•-----------------------••--••---•-••---------••-
..--•---------••-••....-••----• ......e..........................................................---------------------------•-----------•----------------------------------------...---•----•---
Date
PermitNo......................................................... Issued_.......................................................
Date
t THE COMMONWEALTH OF MASSACHUSETTS
BOARD QF HEALTH
...... ............OF.... 4F-°"e07.5A.4jf............................
f9rrtifiratr of TOutpliaurr
TH�� !�'
T ERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (�
'
Installer ff
has been installed in accordance with the provisions of T " The State Sanitary C . described in the
application for Disposal Works Construction Permit No________________________________________ da.ted_-ff &.-_-_-__ ........................
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CrRDA GUARANTEE THAT THE
SYSTEM WIL F NCTIQN SATISFACTORY.
iDATE.....--�1..�-.��-••--------------•--._......._....._..--------.._.._.. Inspector---- ---------------------------._...----.....--•--..._.
j
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
rClds' ..............OF..... ._ Ao�.Zk.........:...............................7 .........
r"
No._�'.................... FEE" ...................
Disposa To tra�rtian rrmit
Permission is hereby grante :-- -----=•-'�•••-•• .... ..__. . ��� �----------..•--------------------•-••-••--------._....._......---_•--•-
to Construct ( o Repai an Indi d Sewage DisposalSystem , f
at No.------ _----------. `t!'••�_l..---- ------ ----•--------
Street •�i �Health
--- -
as shown on the application for Disposal Works Construction Permit No ... .�._:_ ___ _
Board
DATE...................................................... .........................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS