HomeMy WebLinkAbout4495 FALMOUTH ROAD/RTE 28 - Health 4qq5 Fc&� Rad
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.........................
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD gF HEJ.
_.. ..-------OF.............................................------------------- --------.........-•-•-
Appliration -fur Mipuiitti Works Towitrurtion Vaunt
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System a
o tion-Address J or-Lot-No-
... ...... .......... .. ........................................ .......... -------•-------------iL:::------------------
0 dress
W •--------- ----•------------
Installer Address
dType of Building Size Lot............................Sq. feet
U Dwelling IZ"N-o. of Bedrooms__�12--------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building _______________________-._ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures ---------------- ---------------- '
W Design Flow............................................Vallons per person per day. Total daily flow............................................gallons.
Septic Tank/-Liquid capacity/�_Qallons Length................ Width........ Diameter------.......... Depth...--_--__.-.--.
xDisposal Trench—No..................... Width___._F_._.__..___-_- Total Length............. o a 1 sq. ft.
3 Seepage Pit No.__.__1_....___._.. Diameter......-........._ Depth below inlet__.?__.....'. a 1` g 1.c nt trea____.____.___:__sc it.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date--------------------------------------
a Test 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.........--.---.--____
a --•-----------------------------•--•------------------------------------------------------------------- --------•-------------------•------•-----__----
ODescription of Soil------------- --------------------------------------------•-------•---•------------------------.....••--. .--------....
U ---------------------------------------------------------- •••-• •..............................
W
--- ----------------------------------------------
--- ----- -- - -- ------------- --
U Nature of Repairs or Alterations—Answer when pli le.-.-- ---- -- ----- ...........
........- --------------.
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 be n •ss ed the b and o health.
Date
Application Approved By----- . . . ----- --- �- .....
t, a
--------------- -----
Date
Application Disapproved for the following reasons---------------------------------------------------------------------------------------------•--------------•----
Date
Permit No......................................................... Issued--- .. `Z4-------------•-------
Date
1
'------ ------------------------------ ------ --------------- ----------------------------------------
No.. .)vre
Fwic$...JG......................._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 2F HBO r
AOF�.................--------------- ................... ............I.....................................
Appliration -for Bhipwial Works Totwulartion Permit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at: j
�?� 44... ............................ ......................................................................
--------A " .....**------------*----
'o tion-Address or Lot No.
............ ....W,._4---------------------------------------- -------_---- ........... ------------------------- ------
..........
Insta
ife ------
Address
Type of Building Size Lot............................Sq. feet
U
0
Dwelling-L'�No. of Bedrooms_�-------------------------------------Expansion Attic Garbage Grinder (
Other—Type of Building -------_------------------ No. of persons.._____-_-------_------__-__ Showers Cafeteria (
Otherfixtures ------------------------------- ---------------------------------------------------------------------------------------------------------------------
Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons.
04 Septic Tank/-Liquid caPacitv,/_q__!P[)allons Length________________ Width...__.._........ Diameter_--.....--...__ Depth..-_-_-__._....
Disposal Trench—No---------------------- Width----- Total Length_...........j..... To Lial I cif sq. f t.
--------------
ill Va - ---- ---------
Seepage Pit No-------/------------ Diameter........,!.......... Depth below inlet----6------ a cr .......... --------sq. f t.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by------------- ------------------------------------------------------------ Date----------------------------------------
Test Pit No. 1----------------minutes per inch Depth of Test Pit...---.._________--- Depth to -round water-_.-.---.-..__..-..---.
Test Pit No. 2................minutes per inch Depth of Test Pit..__.___............ Depth to ground water---_...--.------. ----.-
04 ---------------------- .........................................................................--------------------------------------------..........._
0 Description of SoiL.---------------------------------------- ----------- ----------
U ---------------------------------------------------- ----------
----------------------
e_Ae?------"I-------------------------------�_- -------------------:-:-:,-----------
------------------ ------------------------ ------
/--- ---------------- ----------
Nature of Repairs or Alterations—Answer iia I- -----------
U when I 2e.-_Z� /Y ---------------- -------------
.............. ----------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------
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 ;b issued the bo
ard rd of health
/A ., d / .,.)
1
Signv(d�
.......................................... ........ ---
.............................. /a---- -------- ------------
0 ---A --------- Da Date
pplication Approved By-------
te
Application Disapproved for the following r sons:-------------------------
...........................................................................I..........
------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------
Date
PermitNo......................................................... Issued......................_................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD T H E A L 'Pt-
..... ..........OF....
............ ............rrtif irate of from
THIS S '71no- Y That the Individual Sewage Disposal System constructed or Repaired
y...b ........ ....... . ------- ................................................... -- ---- --- ---- ------------------------- ---- ---------------------------------------I
lns,ailier� ]4)"
at......... ...i.t........... ------- ------------I . ...... -------- -------------------------------
...................... ... ......................
has been-installed- in accor nce with the provisions of XZK� ,They State Sanitary Code as k.escribe)/in the
Q1 XI of TI
application for Disposal Works Construction Permit No.-E ---------- dated'
-----Zz -
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL(FUNCTION SATISFACTORY.
DATE---------o:�------------------------------------------------------------------ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR H
10,
.................................OF... .......... ..........................
No..............�4.. -...... FEE- —0..........
Dinpatial Marks Tonstrurtion Permit
Permission/,is hereby grafite a ----------------------------------------------------------------------------------------------Z.....................................
to Aal System Construct or Re) an Individual ewage DiZss�l System
o....... .................. .. ............... ...........
. ... ------
--------- - ----- ----------- ------- -at N I
It
as shown on the application for isposal Works Construction Vuction Popp,i o "... .. -- -
- ----------e)....... .... .
-------- .......................... . - --- ----- ..... ................
Board of Health
DATE---- .......4�....................................
FORM 1255 H013BS & WARREN. INC.. PUBLISHERS
6 0 (�
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