HomeMy WebLinkAbout0006 SPICE LANE - Health No......2-1-6-- Fps.... .................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEA TH
--------OF......... ........ ..............
Appliration -for Uiiipwittl Workii Toutitrurtion Vrruift
Application is hereby made fora Permit o Construct (4' ) or Repair ( ) an Individual Sewage Disposal
Syst at /�
--• ----------- --- _ _................�----- -----•--•---------•---- --- .....................--------- ..................................
ocati0 • L No.
O Address
n Iler t Address 7S/C(LSM
Q Type of Buildip J Size Lot_______ ___________________Sq. feet
U Dwelling—No. of Bedrooms------------------ ___ -------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------y__________________ Igo. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures - ------- ---------'-_-------__ __
W Design Flow__ ___________________ ._. .Ilons per person per day. Total daily flow_________._.._._.._............._gallons.
WSeptic TtmkTLiquid capacity.--_--_gallons Length________________ Width.__... -..._.- iameter__._.-..__.-._ Depth...______.._.._
x Disposal Trench—No ____________________ Width--------- .___ al e !_ _ otal leaching area.-_-----_.-.-----sq. ft.
Seepage Pit No--------�-------- Diameter h....:... .. inlet---- Total leaching are a-_--------------sq. ft.
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---.-----_--------.-.-_.
rZ4 Test Pit No. 2________________minutes per inch Depth o est Pit.................... Depth to ground water------------------------
P4 ------------------------------
O *Description of Soil------------- -------------------------------- ----- -- �----------------------------------------------- -----------------------
x
w
z ------------------------- ------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------
V 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 •ssue y a of h It .
Signed _ -_- --- -
--------- ---
---------•------•--
�' ,^ Date _
Application Approved BY L 1
D e
Application Disapproved for the following reasons-.................................. ---•--••-•-•----------------••-•-----------•-•--------
---•-------•--------------------------------------------------••-----------------------------•-----------
Date
PermitNo........................................................ Issued.---.-.-------------- .................................
Date
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD HE A TH
�fsl t'-.--- --.OF.---- :..::... � _ 'C_.--: : -----
Appliratiou -fur Iiopuottl Workii Tow4rurfiou Vrrmil
Application is hereby made for a Permit o Construct (") or Repair ) an Individual Sewage Disposal
Syst a
ocatio dress'+ L No.
rBuildiv�z�.;-e'
- ------------------------•----- ..F_'caner W - Address
ller AddressTyp Size Lot-------__-------------------Sq. feet
U Dwelling.—No. of Bedrooms------------------ ___-Expansion Attic ( ) Garbage Grinder (' )
p-, Other-Type of Building __-____--__.r-------------- No. of persons.___...-_-_---____-______.__ Showers ( ) — Cafeteria ( . )
a4 Other fixtures _
W Design Flow_, ._.._........_ �-tllons per person per day. Total daily flow______ _ _____._._...gallons.
WSeptic Tank Liquid capacity-------gallons Length................ Width. - - iameter_._.. ._._____ Depth ... __.-
x Disposal Trench No ____________________ ���id li....__.__ qa�l�e ,otal leaching area-___.__ _.__. __--sq. ft.
Seepage Pit No -------- Diameter.;�,G . inlet Total leaching area s(l. it.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed bY---------------=--------------------------------------------------- Date....
Test Pit No. L_______________minutes per 'inch Depth of "Pest Pit..______.___.._..,_. Depth to ground water................._..----
�, Test Pit No. 2....._----------minutes per inch 'Depth-o est Pit.df
.._..:..... Depth to ground water.__._-_.___-____--_--
- ---------- `- -------•-•--•--.........................................................
Description of Soil:=---.------•-------•--•---------••------------ --- '!' F ----------------------- ="
x
W -------------------------- ---------------------- •----- --------------------•---•-----------------•-------------------=----------•------=-- ---------•-•--------------------- -------------------------
UNature of Repairs or Alterations—Answer when applicable...................._---------------------------------------------------------..-----------------
---------------------------------------------------------- --- -------------------------------------------- ------------ ---------------------------------------------------------------•-----------
Agreement: x
The undersigned 'agrees to install!the aforedescribed Individual Sewage Disposal System in accordance with j
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 s�.ued&y a of h It
Signed--- ' f
Date i
111///
Application Approved BY-----• -•�`'" - ----------- ----- --- ---<• -- . . . •- -� -�-n �,
Application Disapproved for the following reasons:--••---------------•--=------------------------------ ------------------------------------------------
-------------•------•----•---•----------•-•--••--•-------•----••----------------------------•----•---•-----•---=-----------------••-•---•-------------------•----------•---------•--•--•----•-..-----
Date
PermitNo.......................................................... Issued.........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF..............-................... .......... . ............. ...
err#ifiratr..of 101111mpliaurr
THIS IS T RTIFY, . at the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by - ----- ---- --------------------------------------------------•---
at-----•-----_- = ...
has been installed in accordance with the provisions of Article XI of'The St Sanitary Code as described in the
application for Disposal Works Construction Permit No-------------___ ____ "__ __„__- dated--.:__:._-__-_.______-Via_.______-___-----:--
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-------------------------------------------------------------------------------- Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEAL,TH�
.........OF.... .... j��d� �*r6CG� : .....
No... _ FEE-- ...............
Birivo . ork,q Alan rtion Prrmif
Permission& eby granted-------- - ------- • -------- --------- -----------------------------------------•---_-----
to Cat onstr t )�,ror Repa r-( ),an Individ wage Disposal S
--- -
as shown on the application for Disposal Works Construction r ' t No.. ._. ... Y a"k ed_?-_. ___ .......
k :
oard of� e th .......... yy
DATE -'
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'` FORM 1255 HOSES & WARREN. INC.. PUBLISHERS ' -.
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