HomeMy WebLinkAbout0008 J.B. DRIVE - Health 1 JCLI)
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No..... ................ F>�s...�. . ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD SF HEALTH
. ............OF....... . ..`.. .- ............. ----...-........-.-...------
Appliratinn -fur 43iiipofial 19orkii Tottotrnrtinn Prrntit
Application is hereby made for a Permit t Construct ('" ) or Repair ( ) an Individual Sewage Disposal
Systat --- ... .. .........................
.. �� •••--•- •-
Location ddre or Lot
O net Address
W ✓
Installer Address
d Type of Buildin Size Lot----------------------------Sq. feet
U Dwelling o. of Bedrooms--------------------- ---------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons.--------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures _._.._
W Design Flow. -___................ _____ gallons per person per day. Total daily flow...._.._.__�... f-------------gallons.
W Septic Tank Liquid capacity���gallons p .
Width-______--.---_ Diameter---------------- Depth-------__--_--.-
x Disposal Trench—No_ ____________________ Width.—_........_ ____ tal L t !_�___� Total leaching area...........________sq. ft.
Seepage Pit No ...... ........ Diameter - ppt e .w i ;'....--�� `� To 1 lea ping area sq. ft.
z Other Distribution box ( ) Dosing tank ( ) G2�:�� ( � i .
~' Percolation Test Results Performed by------------------------- ......................................... Date____-----------------------------------.
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water--_-____-________-_-_-
(%, Test Pit No. 2................minutes per inch Dept of Test Pit.................... Depth to ground water........................
---------------------- ------•----•-------- •-- --------•--------•-----------------------------------------------------------------
O '----------
Description of Soil---------. --------•--••-•--••---
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 \I 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 board of health. s
Signe �--- •--• ----•----•---------- -- - -
� � Date _
1
Applicati��. Approved By..._..�//� `� ----- ---- -- ......... _ .. :.
te
Application Disapproved for the following reasons_________________________________
---•-•••••••--•-••••••••-•--•---•---••-•-•---------------•••-••-••--••-•-•-•-•--•-•----•--•--••--••--••-•-----•••••••---••-•-------••--•-•-•----••-•------------•--------•----•---••--•••------•--•-•---
Date
Permit No........................................ .... Issued.......rd' ( � �-----____
' llate
R �.r
No.... .�_ .... ... ... .......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ..'OF HEALT
r --- .O F......6t ..,s ------------------------
Appliratiun -fur Uhipouttl Workii Tomitrurtiun Vrrntit
Application is hereby made.for a Permit�o,Construct ( or Repair ( ) an Individual Sew g Disposal
Syst a f �4 1} • �f N � /
f w, J
� 4
...............
y} ` r�
Ad _ .. f .._____._P
Locatio"
v
_� r Owner Address
f -------•--------•----•---•--••-••---•-•••-••--•-•.. .••---•-•-----•...............................••...........------------••---------••-•••-•-•---••.
..............
.w _•__y s
Installer Address
Q Type of Buildit}gZ Size Lot.................... Sq. feet
Dwelling 4LNo. of Bedrooms___________________ _ -___-Expansion Attic ( ) Garbage Grinder ( )
a Other—Type of Building ---------------------------- No. of persons---------------------------- ( ) — ( )
_______..._. Showers Cafeteria
P4 Other fixtures --------------- --------------- -
Q
W Design Flow ...__.__._ gallons per person per day. Total daily flow..........`.._. .°.._......_._ .gallons.
.
W Septic Tcttik I Liquid capacity. gallons Length................ Width................ Diameter-----........... Depth.--.._-._-.-----
Disposal Trench—Nod ____________________ Wid h._. otal�grCgW��t_ 5-- Total leaching area...................... ft.
t �s »q' ,
Seepage Pit No......-------------- Diameter_-._.___-_ _-_ epth bOi in et ....... ... Total leaching area-------.._._.--___sq. it.
Z Other Distribution box ( . ) Dosing tank ( )
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date..------. ----------------- ------------
,� Test Pit No. I................minutes per inch Depth of "Pest Pit....._.____..___.... Depth to ground water.--...-.-._---.--_-.--
LZq Test Pit No. 2----------------minutes per inch Dept of Test Pit-------------------- Depth to ground water----------------------
- ..
P4 ------------------ ---------------- •--- -------•----•-------- ---------------- -- -----•--------------------------------------------------------
D Description of Soil---------------------------------------- --- -------------'
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'the board of health.
Signe �` cf
� jg .. `
Date
Application Approved BY . --�
---
Application Disapproved for the following reasons-------------------------------- .._._......_..._............_......._..._____._._____._.__._.........._..._
--•-•--•--....--•-••------•------------------•--......----=----•-------•-•-•----•-•-----•--------•------•....--•--•-•--••--•------•--•--------------------.... ........... ------------------- -----
at
PermitNo......................................................... Issued---- �) --••- ....��...._. -•-----
Date
s THE COMMONWEALTH OF MASSACHUSETTS
BOARD '¢F HEALT
Aj
.................OF..... ...
rrrtif iratr of Tontplinnrr
THIS ISLT�)ARTIFY, That the Individual SewagevDisposal System constructed ) or Repaired ( )
bY- „�`= `... - .........•--- `� �`�----- ----- ------ � • .................
* Installer r �
j - --
has been installed in acco dance with the provisions of AriiclewXIrof ,he State Sanitary Code s des •ribe�d in the
application for Disposal Works Construction Permit No:,_:._.-_ __ __-1 _________________ dated... _ c �••............
THE ISSUANCE OF THIS CERTIFICATE SHALL:NOT BE CONSTRU AS A GUARA EE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector ...... �` {....................
THE COMMONWEALTH OF MASSACHUSETTS
+ BOARD TF HE L H
No. FEE •-
R 1 Nor,, ' �unitrurtiun f rrntit
�. µ.
Permission hereby granted__Ul�.i h __....,!' ..A. � ...._
to Constru ( „orR+epair ) a Indivial :SewagsSal Syst ,�f d
at No.-==�•--�- �---- - ----• ----------, " 1 ----- ` �' ° ? G�
Stree
as shown on the application for Disposal Works ConstructiorrINrmitt Dated____ i __
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS