HomeMy WebLinkAbout0193 IYANNOUGH ROAD - Health Y11
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THE CO ONWEALTH O�MASSACHUSE`TTS
BOARD OF HEALTH
....._.........OF......_.. .F,J�/� ��.. ....................
Appliration for i� o tt1 orb Cno�t #rortioo er i$
Application is hereby made for a Permit to Construct ( ) or Repair } an Individual Sewage Disposal
System at:
---------- i'
Loc ;-n-Add ess Lot No.
�. �� Owner Address l
61/��---------------------------------------- 1l ---------------•----
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms____________________________________________Expansion Attic ( ) Garbage Grinder ( )
p, Other—Type of Building Q ---
No. of persons__................... Showers ( ) — Cafeteria ( )
p-' Other fixtures ------------------------------ - - ---------------------------------------------------- -
W Design Flow________________________J........._......._.gallons per person per day. Total daily flow_-_________y's__.______-______--------_:gallons.
9 Septic Tank—Liquid capacity------------gallons Length................ Width-___.___._._.. Diameter..........------ Depth----------.__...
xDisposal Trench—No- ____________________ Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft.
Seepage Pit No/0-0-0----- Diameter____________________ Depth below inlet.................... Total leaching area------------------sq. ft.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by------------ --------------------------------•----•---•--•---------------- Date---.------------------------------------
,� Test Pit No. 1----------------minutes per inch Depth of Test Pit.................._. Depth to ground water.-.___.---__.-.-_.-.....
�TA Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water--------------------
a -------- - ---------------------------•-------- - - -
0 Description of Soil.........C � �7�✓ ...... �----------------•-----------------------------------------------
x
W
UNature of Repairs or Alterations—An w r when ap li ble.____________ _ _____
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 en i ed the bo he
�j
Signe � !Jl
Da e
ApplicationApproved By------------------------------- /C.............................................. ----------•-------- ..a.----------_._.-.
Date
Application Disapproved for the f ollowin easons--------------•-•---•----••-------•-------------•----------------••-•------••---•------------•-•------•----------
-•-•-••--•-••----•----•-•--•----•--••-------•---------------------------••••-•---••••-•-•--••-•-••-----------------•........._....-•--•-••----•••-•-----------•-------.......-------------------•_••-•.
Date
Permit No............ tJ ---------------••--• ........... Issued......�_"- f -----�- _e. t
Date
No......<.t'-.. Fug...... ...................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
7l9 1,61-f --------OF...... ..� #llw -/.A-4_ G... - .-------
Appliratiun -fur Bigpu,5ttl Works Tumitrnrtiun Vrruift
Application is hereby made for a Permit to Construct ( ) or Repair `\) an Individual Sewage Disposal
System at:
Loc n• d Bess Los No
_ .__>�.�.�.------- � ----...... � ....... •------- ......... �f/ yy, : --------------------
--� aJ Owner Address
W '....................
Installer Address
UType of Building Size Lot_-------------------------Sq. feet
Dwelling—No. of Bedrooms--. ..................................Expansion Attic ( ) Garbage Grinder ( )
per, 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.
Seepage Pit No/DQ.Q-_-- Diameter.................... Depth below inlet.................... Total leaching area-----------------.s(l. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-------------------------------------------------------------------------- Date----------•-----------•-----------------
,a Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water.....-..---..-------.._.
IX, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.........---------_--._.
a ;-------------
D Description of Soil---------
-
x C---_ /Pf C ---�2�1��1 .� - ' ��
•-------------------------
V ........---••--•--•---••----••------•-----------•---•-------•------•-------•-----------------------------------••...--•-••---•--.--------.._._........-----------------------------..-------------------
W
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—An w r when appli ble._....-_...._ ---------------------- -------------------------------
��
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 isv6ed the b he
Signed ' .---....... ✓''.G� = >l
Date
ApplicationApproved By-------------------------------- =........................................................... .........................---------------
Date
Application Disapproved for the f ollowing�asons:-------•-----•-•-•-•--......--•---••------••-----------------•------------....-•-----••---..........---------•-•
---•-------•----------------------------------------------------------------•-•----------------------•-----------•-•-----------------------------------------......---------•------------------•--..----
Date
PermitNo...............° !....................................... Issued........................... ............................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Tjlr_ !` jr�rrl-ST�J�1.-
............'..............................OF.............
-
k
Trrtif irate of f'utttpliattre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (>C)
' -
by.................................................: le
/ , Installer /
e '
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described-in the
application for Disposal Works Construction Permit No........ ...................... dated........_....�.-//)_.-...f .......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE `f y ...... Inspector _�7----------------------- ------------------------------------------------
�i'
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
( / .............. G.Gw>`.":...........OF... f.!- ................................
NO...... .- FEE...=.... l-Z....
Bi-spaiittl WorkB ClIunitrnrtiun lirrmit
Permission is hereby granted-----------/'-6:5.... -� t '/�'-��------------------
to Construct ( ) or Repair ( �) an Individual Sewage Disposal System, f-`q ( tT�"
--------•-------•-••--- ----- - ----------------------------------------=••-----•••..•---
Stree
as shown on the application for Disposal Works Construction Permit tNo....... Dated-_----
!
oard of Health ,Jl
DATE........... -..1-----------------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS -