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Home My WebLink About0062 MAPLE STREET - Health ap iAft i c No....2V3--- .... FE$.... •"J...._ THE COMMONWEALTH OF MASSACHUSETTS BOAR® F HE T dam........ OF.....4 .......................... Apparation for 0hiposal Morks Tonotrurtion Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst at: ... ............. ...................... _._. ...... .. y/� -- L�on-Ad /,,/,�/ J A or Lot N.ate //�/-) ... .. ...... .... VP'".,.. 1. ...... V W Q(� Owner d ess .....-.:. .. Y....... �L1......................................... ......... .... ... ........-.._......._. ......................... ---.•................... Installer Address Q Type of Building Size Lot._. .. ... ___Sq. feet V Dwelling—No. of Bedrooms._... ..... ----_Expansion Attic ( ) Garbage Grinder ( ) 114 Other—Type of Building ............................ No. of persons............................ Showers ( ) Cafeteria ( ) Q' Other fixtures ___ ____________________ _ Q - ---•----- -----------------------------------------•-•-----••----------•-•--- . W Design Flow................... ... .. ..._. ___ allons per person per day. Total daily flow............. ..._._.... ..........gallons. WSeptic Tank—Liquid capacity/ allons Length................ Width................ Diameter................ Depth................. x Disposal Trench—No..................... Width....•.__.- _...... Total Length.........__f,._.._. Total leaching area._._.. ......sq. ft. Seepage Pit No----I................ Diameteitf' �_v� !..A Depth Depth below inlet........ Total leaching area._` d 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-___----__-__-_--__-_--. fi Test Pit No. 2................minutes per inch Depth of Test Pit.. .._____........ Depth to ground water........................ 0 -- _. . ......................................................... Description of Soil_____._. . ._. V -•-•-••-•••••••--•.....•••.............••••-••••••.............•--•-•••-•------•-•-------•---..............---•--•-•-•--•--•.....---•-•......---•--.................................................... VNature 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 agrees not to place the system in operation until a Certificate of Compliance has been issued e ar health. Sib' `............................ ._._..za,te . h ��,/•• r._-•-••---•--••-•-•--•-- Application Approved By------ Application Disapproved for the following reasons:.....................................•......__._._._____......_____..._____.___.__..._._...--•-•----••-•••-•- ------------ •-------------------------------------------------- --------------- -------------------- ----------------------------•.------------•-------------------•------------------------.--•_-•- Date PermitNo......................................................... Issued......................... .............................. Date No. I'x$... ,.' ................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE4LT ..rr ,{ ,r,j ... .........OF....... 1� :L Appliratiun for %yo-sal Works Towitrnrtinn Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst at: ' ... .,....... ..... 7 -••---... ........................... Loon-Addre s or Lot No. &A suer W t .� .. ... .ess r f. - j !r[I dress UType of Building Size Lot... j. ......Sq. feet Dwelling—No. of Bedrooms.._.. .................Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building No. of persons............................ Showers � YP g --------•------------------- P ( ) — Cafeteria-------------------- Design d Flow.Other fix... ............ --gallons per person per day. Total dailyflow.._._.__.... _ -__gallons. Septic Tank—Liquid capacrty allons Length................ Width................ Diameter................ Depth.................. x Disposal Trench—No..................... Width..... ....... Total Length................... Total leaching area....................sq. ft. Seepage Pit No....I............... Diameter Q, ' ::. hlfi}Depth below inlet........ ........ Total leaching area..W3 sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date...................--------------------- Test Pit No. 1................rninutes per inch Depth of Test Pit.................... Depth to ground water---.-----_--___-_______- 4-1 Test Pit No. 2................minutes per inch Depth of Test Pit... Depth to ground water........................ � w .. O Description of Soil �b f' • - °� ---------------------------------------•---------------------------•------------. x W UNature 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 agrees not to place the system in operation until a Certificate of Compliance has been issued y,the board�f health. Application Approved BY- �: •. t` ----.. ----- ' Date Application Disapproved for the following reasons:.................. ............................................................................................ .................•---•--------------.....--••-----•--.................:..-----........•........----•---------..........-•--•-•----••--•---•------...---•....•••--•-••--•-•--•-•....--•--•-•-._......... Date PermitNo......................................................... Issued................................._...................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD O7 HEALTH ..... - y � s.... OF..... .............. Tertif irate of Tout hattu Ihat the Individual Sewage Disposal System constructed or Repaired ............................. ....................(..••..)..by................................................. : .. at•--een has installed m accordance with e provisions of article of The State Sanitary Code as de�ribed in the application for Disposal Works Construction Permit:`yo._-_-•_____________________ dated ; :. _, • -_......... THE ISSUANCE OF THIS'.CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYST W .Fy TION SATISFACTORY u DATE....... .................1 1 ? I ..'........... Inspector _r'`C'` = THE COMMONWEALTH OF WASSACHUSETTS,'•,:,; BOARD O,F . HEALTH...t �4. .. ..........; -a'.... .... . t No.... ..... FEE. Permission is hereby grante ...................... to Constr^ct ) or Repair ) an In vidual AeKage ll osal System atNo.` " .......... .a .... r. s_..._r:..... ..... "�" ......... ........: ....... ........................ as shown the application for Disposal W r;cs Construction�treet � Perm&iti.No.--.--...R. >Mated._.= �..-_!e ....... Board of Health ........... DATE-------•-• -•--...--•............... .................................. FORM 1255 HOssS & WARREN. INC.. PUBLISHERS -