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Home My WebLink About0654 IYANNOUGH ROAD - Health N.-tcLnVIL,,St � � No.. Fly$... .......... LTH THEBOARDAOF �HEALTH Ts .............OF..........16/ _......( ---------_-_--------- 4syste : Application for EhiiVosal urko owitrurtion Permit Application ishereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal m t -- --- ��_--=---{[.►i. --- --�- - -v--------j----A--- --------------- ----............................................................. Locat Addres or Lot No. �4=� . ' 14. O/) �r � dres ----------------------- Installer Address dType of Building Size Lot____________________________Sq. feet U Dwelling No. of Bedroo s.....:.............. Expansion ttic ) Garbage Grinder ( ) �- ' p-, Other/�Type of Buildin� G`'� No. of persons Showers ( ) — Cafeteria ( ) aOther fixtures ......................••. -----•-------------•--------------------------------------••------•----------------------------------------------- W Design Flow................................. gallons per person per day. Total daily flow..............2-.:: -....gallons. WSeptic Tank�-Liquid capacity/gallons Length................ Width---------------- Diameter---------------- Depth.-__.--_--_-._.. x Disposal Trench—No..................... Width......... T al L gt _...........__ Total leaching area....................sq. ft. Seepage Pit No.... Diameter__ __`" wept a O�t_.........�_.•... Total leaching area-__I 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.---__-_____________-._. r=, Test Pit No. 2................minutes p inch Depth of Test Pit____________________ Depth to ground water------------------------ ------------------- ---------- ----- ................. - -•-------- O Description of Soil ¢ -- --------I--------------------------------------------------------------------- x --------------------------------- �°'�-1 1E �'r......... ------------------------- V Nature of Repairs or Alterations—Answer 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—Th?bt undersigned further agr snot to place the system in operation until a Certificate of Compliance has been issue Vboardof e t Sig d. •-- ----•----• DateApplication Approved By------ ----- ---- ----- --- ------ ateApplication Disapproved for the following reasons:----------•---•---..-- •--...... ........................................................... --••--------------•--••-----•-•---••---•---•-----•-•------------•---•---------------•.------------------------------•------------------------------------••---•-•--•---------------------------------- Date 6 �_ 7 Permit No......................................................... Issued.......... ----- -/-.3----••---•--•-------- Date ----- ------------ ------� No........................ Film ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA).TH, 0 F..... ................................ ....................... Appliration for 43Wpatial Works Tomitrurtiou Vrrmft Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: fr ........................ ....................................................... .. ............... Locati?n.Add r Lot No. fr ---------- ......... 1-4 ---------A '.+''�..✓'. ,/ O 4,,,r d • -- .......... ....................... ...... -- ------------------------------------------ nstaller Address Type of Building Size Lot............................Sq. feet Dwelling No. of Bedroonas----------------- o --------------- --Expansion a Grinder --- ----OtherlyType of 13uild'ingQ. ..Znt!4__Wf--- No. of persons.__-_____>.............. Showers Cafeteria Otherfixtures ------------------------------------------------------------------------------------------------------------------------------------------------------ Design Flow................. .................i........k-gallons per person per day. Total daily flow____................. --------gallons. WSeptic Tank�-Liquid capacity.,...Ltlj_gallons Length................ Width________________ Diameter--_ -------- Depth__ .__... x Disposal Trench N;-_------------------ Width......... TA ----- Total leaching area___ ___ sq. ft. ------------ ----- ept ow Seepage Pit No... ...............iDiameter../,-,'_k_'_',f `irnt.... 4a_----- Total leaching area....,d _'!l�qft_ 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._____________________.. f1 Test Pit No. 2.................minutes p_9r inch,,' Depth of Test Pit___..._.........__.. Depth to ground water________--------------- P4 ...................... ........... ................................................ 0 ... . . .... ....... ----/ ---------------- Descriptionof Soil------------------ ............... ------------------------------------------------------------------- ................................. ...................... U ------------- -----------------Z------------------------------------------------------- ------------- ------------------------ -------- ..................... ....... -------V, .......................... U Nature of Repairs or Alterations—Answer 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—The undersigned further a r es not to place the system in operation until a Certificate of Compliance has been issued b the board of healthy Y------------------- ------------------------------- ate Application Approved By.".', --- ...... - ------------ I/ate Application Disapproved for the following reasons:....__._..I._.'------- ---------------- ------------------------------------------- ......................................................................................................................................................................................................... Dat Permit No. . ...................................... Issued A 3 ............. Date THE COMMONWEALTH OF MASSACi4USETTS BOARD � HEALTH .. .......OF......... I...................... TWrtifirate of TILImpliaurr TH,)YI �-1-SIT 0. C E R T I F kl) or Repaired :That the 'Individual Sewage Disposal System constructed by.7............ .................................... .......................................................... ---------------------------------- justaller i 4 ----------- ....................._--------------- ............ has been installed in accordance with the provisions of Article XI'of he State Sanitary Code-as des rl.bed in the application for Disposal WorksZ, Construction Permit No-------------ZA-:'r................ dated'___!"4.. ........�7-----:?_� ........... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A G ARANTEE THAT THE SYSTEM WILL FUNCT ON SATISFACTORY. DATE____.__.L 7-S.................. ---------- Inspector... ....................... THE COMMONWEALTH OF MASSACHUSETTS,, BOARD OF H HEALT ........ ..... ..... OF........... . ............ "".f .................................... ...... No....... ...... .......... 3iitrurtiolt Vernfit Permission is hereby granted....::n---" .......................................................... ,to Construe,, or Idepair an Individual)Sewage}:Disposal 5. ystem. ................. at No. Street as shown on the application for Disposal'Works Construction, Dated___� --------------------- ------------- Board of Health DATE. - •- - 125 4------------------N INC -_