HomeMy WebLinkAbout0186 WINDSWEPT WAY - Health o0a
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
4 OF
for.Bis oral Works Towitrurtion remit
-Application is hereby made for'a`Permit,to Construct (k; ) or Repair ( ) an Individual Sewage Disposal
System at
.... .y. �4 .D"'
-L6at,on- or Lot No
= --.. ..... •-------------------------------- ---- ----•-- .
�1 j •`.. Address - ----------•.....................•
`,.. ..........
-•-•--•...............•........••••--•-•••---•---
. Installer' Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms______ __________________________________Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building _._____. -_- No::,of persons____________________________ Show is ( ) — Cafeteria ( )
a Other fixtures
........................................
Design Flow___________ _ _� ___.__ ._.______gallons per person per day. Total daily flow_.._. :�t's ..___:._._______.._.__gallons.
W - - -
WSeptic Tank—Liquid capacity.2 gallons Length................ Width................ Diameter__.___--________ Depth................
x Disposal Trench—No..................... Width Total Length........ Total leaching area :_ sq. ft.
Seepage Pit No------1;.--____-- iameter �:'......... Depth below inlet____________________ Total'leaching area___`._`..rX_...sq. ft.
Z Other Distribution box Dosing tank.
Percolation Test Results Performed by-----•............;' Date
--------------'--..
Test Pit'No. ......minutes per inch Depth of Test Pit____________________ Depth to ground water_-___.__.___.___::_;:_.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...........:_:..........
................................. ....................... ...................................................--..............................
0 Description of S61.1 ________________ ..................................................-
. ' J
x --- ----------------------------------------•-------------------------- - .-
U Nature of Repairs or Alterations.—Answer when applicable__________ __________________________________..........................................._-
Agreement
,.: The under"s-igned"agrees'to install the aforedescribed `Individual Sewage Disposal`System in accordance,'with a
the provisions of.TITLE 5 of the State'Sanita7befn
ode The undersl ed further agrees not to place the system in
operat n ntil a C rtificate of Compliance ha > sued'by the/Board f health.
d
s' �. Signed_ A�_-ot--•-----------•--- •---•--•- --- ,
f,. C Date
4 PPlica"l2on�Approved By.._---- n ; . �. ___'�': v' '` 1<_
v
Application Disapproved for the following reasons________________ ________
Date,
r- ...... ________________ _-_ --------------------------------------------------
r to
Permit No.._- "a`+ -`A ----------» Issued._ � ..............'
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH`
...................................._. .OF.... ........... .............- ...---........- .
Qrrtffiratr of Toutpliattrr
THI IS TO CERTIFY, That the Individual Sewage 'Disposal System constructed (, ) or Repaired ( )
_ �r Installer
t.' .. at----'_ '_•Y.a, ...... "¢__-'� 4'--__S, _.. 1J-'it'.e____a6:C......_..._'_'_____________'_...._.'____-_-_-'--_^-^_ ..
has been installed in accordance with the provisions of TIT IF j of The State Sanitary Code s described in the„ '
application for Disposal Works Construction Permit No.. : "__: _ dated ..----_ _1___ . .l'_s_______________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT. BE CON TRUED AS A GU ANE THAT THE
SYSTEM WILL FUNrj.TION SATISFACTORY. .,-
{ P ,
DATE................. ` ••-•-------------•-•- ,,F Inspector...........
....�
t ......
-..THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............................................................................OF
No...Cr ....
FEE:t-?.:» .
Disposal Work, Toustru' rtto`n "pamit
___Permission is hereby granted...---_ Lk l n ?_...e�..........
___________
---------------•....--------•_._... ._..-- .. ...
to Construct ( �) or�Repair ( ) an Individual Sewage Disposal System
at No.-=----- I x!• r tr�.�:4 ,,. .. `' w
Street =.
as shown on the application for Disposal Works Construction Permit No'_ ..............................
r
i Board of Health »
DATE........"=--- 1 •-
FORM 1255 A. M. ULKIN, NC., BOSTON -
i
r9ho oe
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
--------- -----------------------
OF.
.........................._._..........
Appliration fear Disposal Works Tonstrnrtion Prrutit
Application is hereby made for a Permit to Construct (,Q) or Repair ( ) an Individual Sewage Disposal
System at:
6 lv
....../L, tion..A or Lot No.
---------------•----•--•------------------
O Address
a .... ... ..... ......-- •-------•-•-•--•-•• ---•••-- -•---••---•••-_.._ .........................••----•--•--•.........---
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
'4 Other—Type T e of Building No. of persons............................ Showers
a YP g ---------------------------- P ( ) — Cafeteria ( )
Q' Other fixtures ..................................
W Design Flow............. . .................gallons per person per day. Total daily flow........... ......................gallons.
04 Septic Tank—Liquid capacity_`2��gallons Length................ Width................ Diameter__._____--__-_ Depth................
W Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No....... -------- .ameter......._gt........ Depth below inlet.................... Total leaching areaGk�X�Y..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.....................
fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
0 Description of Soil....
x
U •--•--•--•----••••---•••...-•---....-•-••••-•---••-•-•••--•••--•••-••-•----•••••--•...------•--•----.....••••---•-•-•--•--•••••-••---•----•---•--••-•----------••-•---••--•-•-••••••-•-•••-------•-••---
W
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 TI'i LE 5 of the State Sanita ode—The undersig ed further agrees not to place the system in
operation until Certificate of Compliance ha e issued by the oard f health.
Signed.-. .. . . .. ........... ..................
i ton Approved-By.. :�'.... ......-- •-••••-••-••......-••••--- -' ..`- ............
Date
Application Disapproved for the following reasons--------------------------------------------------------•------------------------•-----------------........_..•--
-----•............................•-•----.......-•---------•-...-•---...------------•---•-------.....-•----•-•......----•-------.--------•-----••---•----------•---------••----••---------•-•......•---
1 Date
Permit No. ........... .. .................. Issued � ��---••---------------
. 8
S tw A c E PE It MIT NO-
L.0 CAT 10 N/
VILLAGE
. 4.
INST IIE R'S NAME ADDRESS
ML
OR OWNER
DATE PERMIT ISSUED �19 �S
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I
DAY
E COMPLIANCE ISSUED
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