HomeMy WebLinkAbout0160 CHURCH STREET - Health is3��s
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................O F.......................-..--..-.........---..-•--------------•__.....-..._.._........_....
.c ppliration for Dhipasal Workii Towitrurflan runtit
Application is hereby made for a Permit to Construct ( ) or Repair ( ' an Individual Sewage Disposal
System at, 2)7. ..........
w 4 � s
Location- ddress or Lot No. /
......... .............................................
rp
O ner Address
W .............
nstaller Address
ype of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder ( )
p, Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
44 Other fixtures ..............................................
W Design Flow............................................ 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.
Seepage Pit No_____________ _______ Diameter......_......... Depth below inlet.................... Total leaching area..................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........................
fX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ._..--------•- --- - •------------------------------•---•----•---•-•-=--•----•--------•-•--._..._..----........._...-----------.....----
ODescription of Soil---------- •--•-•------------------------------------------------------------------------------•-------------•-•••---•--•-
-----------------------------•--.....-•---------------------•---....--------....-•---------------•----._....--•-•-•--._..._..----
-------------------- -----------------------------•------..__...-•-------------------•••••---------•---------- ------ '----------------------------
U Nature of Repairs or Alterations—Answer when applicable_._._ f_._. _..
�.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i�d by t o of liealt
gne _ .... .... . ....... ............ -----..... •---•--- -------- ------ -----••-----
ApplicationApproved By------- ----- ---------- ------•••--...:...---............._.....--•-••••--•-•-•._.......... ...ll ,
Date
Application Disapproved for e f oll * reasons-------------•------------------•-----•-•--------------..._...--------------•-------------- ............._»
.............................................. ......_...................................................................................................................................................
Date
PermitNo......................................................... Issued........................................................
Date
LOCATION SEWAGE PERMIT NO.
1,60 6/1vA t, T 2r3 fa 3j
VILLAGE
UPI STA LEER'S NAME & A0DItE3S
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BUILDER OR OWNER
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DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........... ... ... ...................OF......................... --••------........
Appliration for Diipniial Workii Tomitrur#ion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( )l&�Individual Sewage Disposal
System at: ... (�..................
Location tCddress or Lot No. f
J
........�.._ ...................... .......... .................--_........... ................ ••.......•.... ---------
............
..••......
"••----•.- .......
O ner Address
Zvylpe
� .. - � � ............ _�o...,�- -----------------------------------------------------
nstaller Address
of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic (,,•) Garbage Grinder ( )
P4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ---------------------------•--•. -
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
1:4 Septic Tank—Liquid capacity............gallons Length................ Width................. Diameter............... Depth................
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No---------_---------- Diameter.......4......... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
�.
Percolation Test Results '' Performed by........................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth`to ground water........................
Ri -----•- •-•--•-•------•----- ---------- --------------------------
-•- -------------•..------------•------•-----•---
ODescription of Soil-----------145, _: -----•--------•-•-••------••---•--------------------------------------------------------------
x . ..........- ....-------•---•---•-•---•-- ...... -� -------------------------------------•----. --:_---•- -----------------------------,/..............
....... __-- ----._.-----•---
U Nature of Repairs or Alterations—Answer when applicable..... ,... -� -�a .........
---------------------------•------------------------------------------------------;............-•••••--....._•---
f f -•---------•-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been is ued by t of heatt
F ''
? grietV
E..__. ..._.•• ..._.c` ..-....P_ ...... .......
ApplicationAPProved BY- - ---------- ----.............................................................. ......
Date
Application Disapproved for e f oll ing reasons----------------------------------------=--`......----------...•.= .....................................-
--•----•--•--•--------•---•-••--•••••-•--••-•- -•••••....-•.............•-•------•--...............•......_...........•.... ..................... . .......................................
Dat
PermitNo........................................................ Issued-........................................................
Date
Lh
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
1...................................OF....................
........
(Irrtif irttte of Toutplittnrr .'
THI TO (.7ERTIFY, That the.Individual Sewage Disposal System constructed ( ) or Repaired (
by-. --••• . ;f • --•- ----•• ...........-•---••-----.../ Installer
at...•••.. -- •------- .__.
has been installed in accordance with the provisions of T I 5 of The State Sanitary Code - d in the
application for Disposal Works Construction Permit No. _..................... ....... dated-_ ,.
THE ISSIIA F THIS CERTIFICATE SHALL NOT BE CONST AS A GUARANTEE THAT THE
SYSTEM WILL ION SATISFACTORY.
DATE......1L. .l_ Inspector... ..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
N ..`. OF..................................................................................... FEE.._.... ...........
RoVwiq 'orkn Tonitrnrtion anttt
Permissionis hereby nt . ------ ... -.................................................... .......................................................
to Construct or an ndi ' ewage ispo S
atNo. /--. --• -- -• •••........--••• . ...................... . . .. .. ............
Street
as shown on the pli tion for Disposal Works Construction Permit No........... Dated..........................................
............................... :-------------------------------•-----...--•---.............._
DATE..._ !J_. ....................... oard of Health
FORM 1255 A. M. SULKIN, INC.. BOSTON