HomeMy WebLinkAbout0130 LONGVIEW DRIVE - Health (2) I 3o Inn9 v Ietz Ta:jre.,
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No..__..Yf�.,(_-....... C � U G 7 Fim, . .........................
V THE COMMONWEALTH OF MASSACHUSETTS
ID BOARD F H�LT
ledo5q...............OF......�9 .
ppliration -fur Uiiipniitt1 Works Toustrnrtion Vrrmit
Application is hereby made for a Permit to Construct Repair ( A
n Individual Sewage Disposal
Syst t: � —,9-r/" fly
P ----- - ------_------
A = =
L atio - res �F �lbot Owner ress
Instal er Address
U /peofding Size Lot............................Sq. feet
Dwelling kNo. of Bedrooms..................�._--__--__---_____-_Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures. ........
_
------ ------- -
W Design Flow---------------------- r.____-._gallons per person per day. Total daily flow.............5a. __._.. ...........gallons.
W p ---------- --_-- ... L g Depth................
x Disposal Trench�N Width... g Total Le th_._..___. T al leaching area_.___._�:-_._.-...sq. ft.
Septic 1'an —Liquid capacity__.. gallons Length________ Width................ Diameter
------ -- ----
Seepage Pit No. Diameter _.-.._ epth e1- ml tal leaching area. --- sq: ft.
Dosing
Other Distribution box
z ( ) g tank ( )
Percolation Test Results Performed by Date----.-•---------------------------------
,� Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water..______.__.__.___.-_---
rZ4 Test Pit No. 2................minutes per inch Depth of ' est Pit------------ :_..-.
a ----------------------- .............
-------
Description of Soil----------- ._
x
W
UNature of Repairs or Alterations—Answer when applicable.._____________________________________________________________.................................
-----------------
Agreement:
The undersigned agrees to install the aforedescribed In g idual Sew
a isposal System in accordance with
the provisions of Article XI of the State Sanitary C e undersigne furtl er agrees not to place the system in
operation until a Certificate of Compliance h een is l y the board eal i.
Sig -- ------- -- .:-------•- - -Cls cv -------------•-----------------
/Da.Application Approved BY Ems' - ate
Application Disapproved for the following reasons----------------------------------------------------- - --------------------------------------------------------
.............•--------------•--•----•-----•---------••---•-------------....-•--------•-----•--••-----------------------------------------------------
Date
Permit No. Issued /
Date
s,-
No...... -•---• Fiz . ....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALT
f.. ..... --- ------- ---OF..... ........... .......................
4
, ppliration -for Dispo,itt1 Workii Tontitrurtion Vrrmit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sew,ag�re Disposal
- ----- -- •• ----------- ------ = =---- -----
L atio -A res ) /� or Lot o r"A
7ypeof
i� ..�=-..... ---- --- -- ----- S�fi'f+�" '--- , '�,!g,,' "j,.+�-'' --------- •------ _.....Owner d ress
--•--•--------- ----•--• --•---• �{� on -••------------••---
Instaler Address
uilding Size Lot............................Sq. feet-
,ew, Dwelling 4KNo. of Bedrooms.------------------- - ------------Expansion Attic ( ) Garbage;,Grinder
Other—Type of Building _____ ______________________ No. of persons...______--_________--__-.__ Showers ( ) — Cafeteria
Q` Other fixture �.�} --------------------------------------------------•-------•---- ----------•---- `
Design Flow...:............ ...: ......gallons per person per day. Total daily ...........gallo:-s `
MSeptic Tank—Liquid capacity-. -- _____gallons Length_______________ Width.._-............ Diameter____-.---------------- Depth...1
xDisposal Trench N . ..._..___.•.____.___ Wi th__. of 1 Le t _ _.__ T al leaching area-------------- _sq. ft
Seepage Pit No_______ Diameter ..._, elei inl _--:___ otal leaching area._ . .--__--____sq. ft.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by __...._..._.________ _________:____________._____________________ Date-,'-,__------------------------------------
Test Pit No. l................minutes per inch Depth of Test Pit--------------------- Depth to ground water-----------
Test Pit No. 2________________minutes per inch Depth of ' est Pit------------
"Depth to ground water.---_-_-------------
------------------------------------------------------ ---- .........
Description of-Soil---------. ................. _
x
UNature of Repairs or Alterations—Answer when applicable-.___:==---------------------------------------------------------------------------------------
----------------------------•-•-----•--------------------------------•----•--_ -----------------------------------------------------------------------------•------------------------------------------------
Agreement:
- The undersigned agrees to install the aforedescribed In idual Sew isposal System in accordance with
rthe provisions of Article XI of the State Sanitary e under signe fur'tl er agrees not to place the system in
operation until a Certificate of Compliance h een iss e y the boar&o;e
Si ,
i�/.-----------------
Application Approved By- " - - -
i Date
Application Disapproved for the following reasons--------------------------•---•-•-•- :_--: ----------------_.._:__.-....._._..._..._________________
---------------•--•--------:-•----------------------------------------------__-----
_ Date
Permit No.........................................................
-----•-------•---•--• Issued------ ..........
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
...... . .... . ........OF............ .. : . .........
Trrtifirate of Tomptialtrr �,,
IS IS T CERTIF , That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by.. J.0
------------ - ----- ---------x---•••-•••--- =--------•••-----•-•.-----•---••---•--..._.-�---•---------•-------------
In alter
has been installed in accordance with je'provisions of Articl of The State �nitar_v e s descr` ed in the
application for Disposal Works Construction Permit No.__._.._ coo /
application dated--.-��i/ -- ---- .......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A.GUARAPITEE THAT THE
SYSTEM WILL' FUNCTION SATISFACTORY.
DATE.....MY, --,/7— Inspector__.. ----------------����//...............................
!� '
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 0- HEALTH
d-�
OF.... ......
No.-- _--------- ,FEE........................
� ��o Ott or1� � �t�trttrtiott �rrmit
Permissiomiyreby granted
L
Co ) Re air ( ) dividual Sewage'�ispos 1 Sys m g
No. �Z
.r
Street a 1 -
s shown on the application for Disposal Works Construction Pe No:_ _._ -__ - �� -_-. - D-tted _
- �!
Board of Health
-----•✓ --- -------•-•-ORM 1255 HoeSS & WARREN, INC.. PUBLISHERS -