HomeMy WebLinkAbout0078 REBECCA LANE - Health /03
No........ . ... ................
... .....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD.r HE H..
I` � �t,�,,ti ---OF...... . ... . ...........
Appliration -for Uiiipwial Murky Tonfitrurtion Vanift
Application is hereby-made for a Permit to Construct or Repair an Individual Sewage D* sal
Syst at
... .......... ........�.3...;7........ ......... ................................. .............................. .............................................................
Location'-*Ad or Lot No.
or "',v,,,a, Sewage D a,...... ..........
........ ......................
Location- d
Owner Ad
....ay`-
Installer
............. ... ........ ... . ............................ ................ ...... ........................... .. .... . .........................
9t:!
U
AddressType of Building Size Lot.49/----�.'_'0�-3-Sq. feet
Dwelling—No. of Bedrooms-_5Z....................................Expansion Attic Garbage Grinder
�1 419)
a4 Other—Type of Building ____________________________ No. of persons....____.___-_______.____-__ Showers Cafeteria
PL4 Other fixtures -------- ---------------------_--------------Desi n Flow........... ... ...........................gallons per person per day. Total daily flow................................... ....gallons.
1:4 Septic TLiik—Liqtiid capacit/ Ion's Length................ Width.____.._....-_._ Diameter____-..._--_____ Depth----------------
Disposal Trench—No. .................... h...................p Total Length To ft.
Seepage Pit No o .......
leaching area
-------<� leaching area------------------sq. f t.
Z Other Distribution box Dosing tank I- 7
Percolation Test Results Performed by------- --------------i.................................................. Date----------------------------------------
Test Pit No. I----------------minut6perinch Depth of Test Pit..________________-- Depth to ground water------------------------
(4 Test Pit No. 2................nimutes per inch Depth of Test Pit.___-___-._--_______ Depth to ground water__.__._____-_:______---.
0 Description of . i-A-----/----------;�---------
.......0... ---------------------
U ....................................................................................................................................................................................... ---------------
W
----------------------- ---------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable.................. ----------------------------------------------------------------------------
--------------I-----------------------------Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article Xl 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 b9ard of health.
Sign . .... . ...... ---------------- ...... -------- ..
Date
Application Approved By-------- -- .....................................
Date
Application Disapproved for the following reasons:................................................................................................................
...................................................... ------------------------------------------------------------------------------------------------------------- -----------------------------------
Date
PermitNo......................................................... Issued--------------------------------------------------------
Date
—--------------—------------------------------------------------
No......................... Fmc............................_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH."/
t........ _'..�. ..`..!... �.. -!-...-- .............................
Appliration -for Uiipuiittl Works �T.owitrurtion Vrrttiit
Application is hereby made for a Permit to Construct (4-/-) or Repair ( ) an Individual Sewage Disposal
System at: � -y , � ._..•� `, / ,�"
f Location-Address or Lot No.
Owner �� Address
-•-•------•---------- ------•--------------------•-- ...........Adddresress -�
Q Type of Building / Size Lot.. _gt._%�.�- �Sq. feet
U Dwelling—No. of Bedrooms._°------------------------------------Expansion Attic ( ) Garbage Grinder
N
aa4 Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Other fixtures .----------
._ �'---•-----•---•-------------------------------------•---_---------..-----------------------------------------------------
W Design Flow----------- f.........................gallons per person per day. Total daily flow............. l__ __��_--_------.....gallons.
WSeptic Tctuk—Liquid capacity`; "gallons Length....:........... Width................ Diameter---------------- Depth----------------
x Disposal Trench—No. --------_-__ -__ Width----------------.;Total Length --_ --z Total leaching area_.? G �.:_.sq. ft.
Seepage Pit No.................... Diameter: '__ '__._..._`Depth'lielow inlet � "' "° ` Total leaching area.._ sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) p o4`' 7 b
Percolation Test Results Performed by-------------------------------------------------------------------------- Date---------------------------------------
,� Test Pit No. 1................minutes per inch Depth of 'Pest Pit.................... Depth to ground water...----._-.---.--_-.....
rX4 Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water.-.--.-.--_.-_-.---_-_-
O _ 3 j-- -------••-•--••- ...............;
Description of Soil 4 ` k G ---?!!N----- -------
x
W
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 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 board of health. i
���. // �.�• f /
Sign ... . ...
=' ''/' f�, }- f7
Date
Application Approved By-------- --• C/ w` ..vl!L....... .............. ...............'Z �.v
Date
Application Disapproved for the following reasons-------------------•--------------•-------------••-----•-•-------• ;----------------------------•----------------
-•........---•----•--------------•---.....---------------------•-------...-------•-•---••---....------•----•--......----------------•-...............----•-----------------------------..-----------•---
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH `
.. .
Trrtifirate of 0.1.rrmlifta err
THIS IS,,rTO CERTIFY, That,the`Individual Sewage Disposal System constructed (� ) or Repaired ( )
f..• . ''.'•✓ ...sue
by-•------•-••. =
- Installer
at- ------ --------------- ri-i-�---- -- -- --' --' /
---------------------------------------
has been installed in accordance with the provisions of . ,ic I_of The StatecSanitary Code as descri ed in the
al
application for Disposal Works Construction Permit No...............57_.U..........._.. dated...__,/"_X.'...7 ........___..._..
THE ISSUANCE OF THIS CERTIFICATE SHALE. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------ /1--- /' / ................... Inspector----- ----- - . . . .............-----------------------
THE COMMONWEALTH OF MASSACHUSETTS
f BOARD -OF HEALTH
A
07� 3 f
No......................... FEE........................
Bi-spotial ork,i .Tonstrurtion ,permit
.. �_
Permission is hereby granted_____________ _
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No------------------
` Street
/ - � '7 L
as shown on the application for Disposal Works Construction Pe No. .... . Dated.../___....___..._.......................
DATE................................................................................ Board of Health
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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