HomeMy WebLinkAbout0114 LILLIAN DRIVE - Health (2) 114 1-SI. Ls zq8-2781
No.---. (�,...................
A/C � THEBOARDCOMMONWEALTH OFHQff �ALT ETTS
Z
.�vOration -for Biivuiia1 nrkii Cnnnitrnrtiun �guift
_
_��f 2- -
Application is hereby made for a Permit to Construct ( or Repair ( a Inds idual Sewage Dis osal
System at: ��- cT/ yll�
-- A
---------- 9" .... . ........... . _------ '��+'-.......
Location- ss . o Lot N
.. �.... -- -----
Owner Address
,' Insta ler Address
QType f Building, Size Lot------------------ --------Sq. feet
U Dwelling—No. of Bedrooms------------------------------- - -Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ---------------------------- No. of persons_-____---________---__-__- Showers ( ) — Cafeteria ( )
a' Other fixtures -----
W Desi n Flow----------------------- -..... _ Mons per person per day. Total daily flow---------------- -- lJ�...-gallons.
g It ��-
WSeptic Tank—Liquid'capacit _ allons Length---•------------ Width------ -- ------ Diameter-----_-------- Depth----------------
x Disposal Trench—No -------------------- Widt ._....____�__�_�'-,,.�otal Length-------------------- Total leaching area _ sq. ft.
Seepage Pit No......... ........ Diameter._ 7l i Total leaching_�I pthbeow nlet_.._..._._.. _.____ ota area -- nn—sq. ft.
Other
bution box
Dos
Z Percolation ITest Results ) Performed bying tank (-----)---- C�---� - Date--------------------------------- -----
ar
a Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water_..,T-�-._-..----
fi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...-.-.---_------___.--.
--------- --------------------- -----------...........
. . - -- •----•-•----------
0 Description of Soil------------- ---------------_-----'� a� �'`{ � �.
• =`-� "
x
V ...---....-•--••••-----------------------------•..._•--................. ----................--••----•--•---•--•---•---......-•---.....-•--•-•---------------------------------------
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
the provisions of Article \I of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been su d y the board of he -h. .
jL
ned ----------------------- -•--- : ..
---•- ._...Y_.. -----•-•--------------
Date
Application Approved By-----!K-------
-,r
Date
Application Disapproved for the following reasons--------------------------------------------- -------------------------------------
...................•-•-•-----------------------------------------._.......-••---•-•••--•-----•--•--------•---------------------•----------------------------------------------•-•-••----•--------------
Date
PermitNo........................................................ Isiued........................................................
Date
= �r .., ..
No _. FEE. .......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEA1
Appliratiun -fur Biupmat Workii Tonitrurtion MU
Application is hereby made for a Permit to Construct ( iror Repair ( an Indi ldual S Disivsal
System at: Q d
----- - ----- --••-• --
.,
ca n_A ress or Lot No.
yLq` .. ----------- ................................... •-•--••----------•...--• ...................
W Ow r � Address
Instal r C� Address
d Type of Bu Idin Size Lot............................Sq. feet
U Dwelling VNo. of Bedrooms__-_ " ________.___Expansion Attic ( ) Garbage Grinder ( )
aOther--.Type of Building _ __________________________ No. of persons.--------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtur0�4
-- ---------------------------------- � ---------------
Design Flow _______________ ___ Mons per person per day. Total daily flow.._.._. _-_gallons.
9 Septic Tank—Liquid cap a11ons " :Length---------------- Width - Diameter——......:... Depth----------------
Disposal Trench—No .................... Widt ___ tal Length.................... Total leaching area_- sq. ft.
Seepage Pit No.____.._. ..,Diameter _� below in�l`et____________ ______ To, 1 leaching area„ " sq. ft.
Z Other Distribution box ( ) Dosing tank:( ) G '
aPercolation Test Results ,Performed by ___ ___________ _________ _________ ________ _________ Date:_--- ------------------------
Test Pit No. 1.................minutes per inch Depth of Test Pit---------------------- Depth to ground water .. �c-__ __-.
f� Test Pit No. 2................minutes per inch Depth 'of Test Pit... ................. Depth to ground
- n water-_-- __---__--__:____.
-•-•-••------- ------- ----. ------
V Description of Soil----- -- •-- ------
----------------------•--•--------------------- ---•--•--------- -------- ----- - -- -- .......................:---------------- -•--•-►------_--------- ------ -
W Y
UNature of Repairs or Alterations—Answer when applicable _______________ ., -_ _-___-___-___---..
� 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 a„ssu d y the board of he h
ned---- -- i --- - � _• -•- ate------ ------
D
Application Approved BY ` ..::-• :_ = ,0-
- - J - Date
Application Disapproved for the following reasons: -------- == = =
'-Date
Permit No................ Issued.:_._.:--------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
uvs
o F.. .r �..r-a
•,F ...... . .......... ...... .:.... t ..
(E.rrtifiratr of Tom; liftaurr
f_
OTHIS , CER' T at.'the Indivi ual Sew ge Disposal System constructed ( or Repaired ( )
by �� > ------ ------------ --- ''
l Instal
--
has been installed in ac o'rdance with the provisions of Article XI f he S e Sanitary Coc e a des ct i d in the
or. application for Disposal Works Construction Permit No---------------- _--""-- ---------- dated -_- 7_-_ _------ _ :, ►___.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GU RANTS THAT THE' „
SYSTEM`WILL UNC ION SATISFACTORY.
DATA;'_:. --------------•-•---------- Inspector t-^'" _ _' '�•
.• THE COMMONWEALTH OF MASSACHUSETTS
411
: 7
BOARD O HEALTH"`,
.OF..
1
• "yy
No.__. _ FEE_2___..............
%nvo IV ork Cn nitprtiun ! rmft
a_r hereby.gra Permission is nted--- -- -- -•-•--
a
to Conxtrt ,`/f'o R an ( J) an Indivtal Sewage Di dal Systerr
at - 1
' - St eet
as shown on the application'to Disposal Works Construction' w t No.___ ated - /
.,. ......
,l
DATE /
y� .______ __ __.__-I------ ------ --�___._.--..__._.-.___....____.____
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', r� FORM 1255 HOBBS'&'WARREN. INC.. PUBLISHERS
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