HomeMy WebLinkAbout0000 ROUTE 149 - Health (,�i,
No. ......i3
ID3 ^ f THE COMMONWEALTH OF MASSACHUSETTS r .
BOARD F HEAL H
...........O F......
Apphration for Uiipuottf arks onstrurtinit Prrmit
Application is hereby made r a Permit Cons or Re air ( ) an Individual Sewage Disposal
Lq - ddress or Lot No.
................... ............. r- 4 ...............................................
9 y wne `� Address
W (�
Installer Address
UType of Build' Size Lot____________________________Sq. feet
Dwelling—No. of Bedrooms____________________________________________Expansion Attic ( ) Garbage Grinder ( )
p-, Other—Type of Building ____________________________ No. of persons........._......_........... Showers ( ) — Cafeteria ( )
Q' 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.
3 Seepage Pit No--------------------- Diameter____-_______________ Depth below inlet.................... Total leaching area------------------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-_.............____-___.
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---_-____--_________----
P4 •--••--•-•••----------------••--••-•••----•-•••-•••••••--•••---•••••------•--•••-•-•-•-...•••----••---•••-•••--....-•••--•-•------••---••••-•-•--•----------
ODescription of Soil--------------------------------------------------------------------------------------------------------------------------------------------------------------------
x
U ---•------------------------------------------------------------------------------------------------------------------------------------- -------------------- ----------
W ---••----•- - - ------------ --- ------ --------------- ------------ --•---•--------
U .Nat-ure of Repairs or Alterations—Answer when applicable.- ___! __ __ � � ________•___-____.
•--• -•••--------------------•---------------------------•-•--•---•---•••-----•••-------••-----•--•••-•--•-- t-------
- -- - -- -- - --- ----- ---------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordancef 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. ,f
Date
Application Approved By------------- ---------`�-=-------------- -- Y
Date
Application Disapproved for the following reasons:..................................____... _
------.............................................................
---------••-•----•--------------
Date
Permit No......................................................... Issued-------- ---_ __ ....
...
13.........
Date
.......... _ ....••.........................................••..•............................... ..........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
lid... In—..0F........... . . .... .. .. . . ... ..- . . ...............
CIrdif it - A Tiaiii phatirr
T 1 S TO CER the Ind• idual Sewage Disposal System constructed ( ) or Repaired ( )
by....... ---•--••• -- ... --• ................... .........................................
Installer
has been ins alled in accordance with the provisions of Article.XI of Th State Sanitary Code as describe the
application for Disposal Works Construction Permit No................l__�__�_________ dated_.;,T�- _/._�__._.._.________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE----` `- t�e "�
-------------------•------------------------...----.__..-•----- Inspector------A
------------------------------------------•-•---------------••----
f
No. .. Fxm....c ........ .. ;
THE COMMONWEALTH OF MASSACHUSETTS r .
�O kRD gF HEAL_ H
t O F
Application is hereby made for a Permit t Constr t or Repair ( ) an Individual Sewage Disposal
yet at:
L�t,- - ddress or Lot No.
........................... __.•----- -- .............................
�.-�.-----------------------------------------------
Ownek Address
L» Installer Address
UType of Building/ Size Lot----------------------------Sq. feet
Dwelling=No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
QIOther fixtures ......................................................
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic 'rank—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 ( )
aPercolation Test Results Performed by.......................................................................... Date----------------------------------------
0-4 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
(14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-_-__-:____-_..._______-
9 ---------------------------•-...-•••-•------•---•••----------------•••-----•----------•....._..---•......
--------
-----•-•-----------------------------------
0 Description of Soil---------------------------------------------..----.......-----•------------.....--------------------------------------------------------------------------------------
U ---------------------------------------------•----------•-•---•-•-••-•-•------•--------•-••--------•------------•-----•----••--•----••-----------------------------------------------------------
---------- - - ------------ --- ------ ------ • .
U Nature of Repairs or Alterations—Answer when applicable._'"-_____ t' ` _ ________._ _
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.
Signed-.. ----•-------•--•----••----------------------•-••......•-•-•-•--
Date
5L -L1_ _ _ `APPlication Approved By-------------- - - --- ---- _____ ------------------ --------------Date
Application Disapproved for the following reasons------------------------•----------------------------------------------------------------------------------•--•--
..-----•-------•----•-•••----••••••••----•--••-----------••---------------------•----•.......---------•--I-------••---•-•-----•---•---•----------•-•---------•-•-••-•-•------------------------•-•--.
Date
PermitNo......................................................... Issued........................................................
Date
I
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
..... ......OF...........
� s
(Lrrtifiratr ,a fIgnt;itittttrr
TIS S TO CER7� Y T t the Indi dual Sewage Disposal System constructed ( ) or Repaired ( )
by-•-•-- -- --•-- . -•-- •--------•------ ------
Installer
at.....................• -----= =------------------•----------------------------------------------------------------------------_-------- ..............................
has been ins lled in accordance with the provisions of Article XI of Th State Sanitary Code des ribed ' the
application for Disposal Works Construction Permit No................�_ .__ ...._....... s dated__; ., ..........
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 OF HEALTH...:...... "..... .....OF_......3.t�.94:.. ............
No.--- •-•--- FEE----
E
Binpvii orkii r#il antic
Permissionis reb gran d.-- .. .... .. ..--- ------- t......... ----------•-------------••--•-•-------•-•••--•••-•-----•-----
to Construct ( ' .) r _pair an male_age Di osal ystem
atNo. A "`�---; •�..•..----. - -- ��� -------------------------------------
--
a Street
as shown on the application for Disposal Works Construction e\r�t No._ :.... _`___ ated. __./ '__.__.tom_.-��____
..
•• -• Board of Health
DATE- . --. ..._'
FORM 1255 HOBBS & WARREN_. INC.. PUBLISHERS
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