HomeMy WebLinkAbout1426 MAIN ST./RTE 6A(W.BARN.) - Health 14aG, YYlarn G/12$zGp-, � .�j.
No..Ja.t :........ .............
THE COMMONWEALTH OF MASSACHUSETTS
BARD E HE LTH
V \(1 O F...... .............................
Appliration for 43hiposal park aanstrnrtion Vrrmi#
Application is hereby ma a for �ermit to Construct ( or Repair ( ) an Individual Sewage Disposal
�'
System at: a;j, d
C ....... . ......... A
Location-Address or t o.
W Owner Address
a ................................................... •-••-•....•••••------•............•••--"""......•••'
Installer Address
UType of Building Size Lot............................Sq. feet
�-, Dwelling-No. of Bedrooms------------ ..........................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building
a yp .____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ------------------------------- ----- ------- -------
W Design Flow._?................... --gallons per person per day. Total daily flow......- ---___gallons.
WSeptic Tank+Liquid capacity/,dl.lgallons Length................ Width---------------- Diameter------------..._ epth ---------------
x Disposal Trench—No..................... Width.................... Total Length------------ Total leaching area_ _ �------- ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching are __----------------sq. ft.
Z Other Distribution box ( ) Dosing tank
04 Percolation Test Results Performed by.------6_�._.,�UL G
a ••-••--•-••--•••••• Date--------------------�--�•-----.
Test Pit No. I................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______________-___.___-.
a ••••-_-- ---------------------------- ------------ -----------•-• --- ------. .... ............ -•------------
O Description of S 1 '- '� -�-� - � --------
,�tt,, ``t� /
U ------••-- - ..-14...... --••'=• --$ .. ------------------
W .............. ...."-
c-. �SR.r� T ----._--__------------------
V Nature of Repairs or Alterations—A swer 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— Tlie undersigned further agrees not to place the system in
operation until a Certificate of Compliance,has be n issued by the boar of health.
Signed �'� L f Yx"W-2 - --------
�y �fc� Date
Application Approved By-------- - -- /J r � r
ag to
Application Disapproved for the following reasons------------ ----------------------------------------------------------------------------------------------------
••••.....••••••--•-•••••-•••------•n••---•••-••••••-------••-•••••••-••---•-•-•••••-••-•--
1` Date
PermitNo.•-••••-•••••---•••-•-•••._...-••••-:.................... Issued........................................................
. --_..... _..���._�._. _ Date `__•___._._____
THE COMMONWEALTH OF MASSACHUSETTS
•
BOARD F HEALTH
Apphrution f 6r. 3i5pusal Marko Tuuatrurtauu Virutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
Y
.:
S stem at
Location-Address " or Lot No.
! -
Owner Address
W
Installer Address
UType of;Building Size Lot__________________________Sq. feet
Dwelling To. of Bedrooms___________:�--_---___________________Expansion Attic ( ) Garbage Grinder ( )
Other-Type of Building ............................. No. of persons---------------------------- Showers ( ) — Cafeteria ( )
P4 Other fixtures --------------------------------
W Design Flow.......................-5`10------------gallons per person per day. Total daily flow.............. .._""°0-----------gallons.
WSeptic Tank 4--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......................._.!;�:.....___.
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____________________-__.
O Description of Soil e , s s C" - � e �"�---` - -----------------------
w ! -------- -------- ----•---- -•----_--- ----••---------•----------------------------- ---....----.......-----•-------•---
U Nature of Repairs or Alterations—Answer when applicable-----------------------________________________________________________________________________.
-----------------------------------------------------------------------------------------------•----------------------------------------.......-----------------------------------------------------•.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
r 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 •-•------ ...........
ate
Application Approved BYE I'-- .: ---
Application Disapproved for the following reasons:----•------------------------------------------------------------•--...-•-•--•------••-------•••-_---------..._.
-------------------------------------------------------------------------------------------•------------...------------------------......------------------------------------------------------------••--
Date
PermitNo......................................................... Issued................._.......................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................OF....... '` ` �.� ..........................
��rti�i�ut�e of f�uut�li�tu��
T S IS TO CERTIF1 That the Individual Sewa e Disposal System constructed ( or Repaired ( )
�.."" = =
Install er
has been installed in accordance with the prov sI ions of Article XI of he State Sanitary Code as described in the
application for Disposal Works Construction Permit No....................../.3. �_. dated.._ _ .. _-.-:----_..._.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A G GRANTEE THAT THE
SYSTEM WILL FU TIO ATISFACTORY.
DATE ----.....--•---- Inspector--------•--- - ------------------------•..-•---
THE COMMONWEALTH OF MASSACHUSETTS
BOARD P F HEALTH
...
No _.... �- -----.. FEE--- ................
°(� u�t� .i�or�t-• �rutit
Permission is ereby granted____ „ „, __..._.. -�C:_� ...: ... . .......`.__..........__
--------
to Constru t ( or epa ( ) an Ind'vidu 1 Sewage Disposal System
at No. .� --- � .
Street /
as shown on the application for Disposal Works Construction Per �t NaJ. _ - ,�_- Dated.... ./.
. .
-
•� Board of e lth- -
FORM 1255/HOBBS & WARREN. INC.. PUBLISHERS