HomeMy WebLinkAbout0170 MITCHELL'S WAY - Health (2) ; w M��eV��6Ls UJa�
1-I�`� - 2qo -� � fb
J
�t '
~-� T\-- \ / i/�� '
� -qL� �~�L�
/Nm.............K.......... Fimic. ..........................
THE oOwwomvvsAcre OF wAssAcxussrrs
|
� BOARD F HE
- ---
----------OF........e
C) Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
Syst9T at:
1p or
��.____��~�_\ _____________________ ______���������_____ ~~`~~ ____'______________
��^u= � Address
Type of
� Size1v ��u No. of BedroomsExpansion Attic N°,
0r �6�r v�m
Other—Type of Building R�� �_--
�
I�o� of prrxou»----------- 5�v��ra ( ) -- Cafeteria ( )
'~ (}t6�r 6�tvc�s
~� -----------------------------------------------------------------------------------------------------------------------------........................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
Septic Tank—Liquid capacity............gallons Length................ Width------ --------- Diameter...... --------- Depth--.----
Disyooa Trench--No .................... Width.................... Total Length.................... Total leaching arm----------.........sq. h.
Seepage Pit No..................... Diauetcr---------- Depth hcln= inlet.................... Iota lracb�garea------'sq. ft.
�� Other Dis�ibo600box ( ) Dosing tank ( )
~~ Percolation Irat Results Performed by...------------------------------------------------------ Date--..-----_--_---�
� Ieot Pit No. l................minutes per inch Depth of Test Pit.................... Depth to ground water.-----_--
Iea Pit No. 2................minutes per inch Depth of Test Pit.................... Depth toground water----_----
ps -.
~~ Description ofSoil.--�� -' -..------------.--------------------------
_'-_-'__.-'-_-----_-'-___-'--____-----------_'-_'___'._--.__-_-'___-_'-----_---_--
_-.-_.''''''-'---'- -_-__-_-__--_--_-'_---_---_-_-_-_'_-
[j Nature u6 Repairs or Alterations—Answer when --_-_-.-_--_.---'----_----------_-'
--_-'--'-_.__.-_'___.'--------_----.__-_-------'-_--_.---_-----__—.
Agreement: �
The undersigned agrees to install the uforc6escribcd Individual Sewage Disposal SysmnnJo accordance with
the provisions of Article XI of the State Sanitary Oode— The undersigned further agrees not to place the system in
operation until a Certificate f Compliance has been issued by th 6 d
.................................................. ................................
ate
Application Approved By'-- ' . __
�r x ,� u"�
Application Disapproved for the /oDvmv�q7reasons:-.-------'.-_--��----_---.--.------_-------_------'
........................_^...............''...................._............................_...........---------------------------------------------_------------ -- '------
---
Permit No.-----------------_-----_'--' Issued-'�� ��'~�/ate
------'----
r t
THE COMMONWEALTH OF MASSACHUSETTS
BOARD PF HEA T;H
:. . _ of ..... .
ApplirFation for RspaoFai Works Towitratrtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
.System at: rZ.W e 5
iLocation Address
t f p i or Lot No.
..tseA ...........
..........A:�:.
_________________:........................ "_6 6_______________________________________________________________________________
Owner Address
C
a .........--------------------------------Installer Address
d Type of Building Size Lot_____________ _____________Sq. feet
Dwellin —No. of Bedrooms,:-________ ___________________________Expansion Attic 10"0 Garbage Grinder (14q
aOther—Type of Building .......................... No. of persons____________________________ Showers ( ) — Cafeteria ( )
Otherfixtures -------------------------------------------------------------------------------------------------•---------------------------------------------------
WDesign Flow......................................______gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity............gallon' s Length------------_- Width---------------- Diameter---------------- Depth_.-.__________
xDisposal Trench—No_____________________ Width.................... Total Length------------------_ Total leaching area--------------------sq. ft.
Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area______--________._sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by...................•••••--••--••-•------=•---••......-•--•----•-•••••_••_. Date-------------•-•-•--------------------
a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_:____________________-.
w . Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(� ------------•--------•-----
Description of Soil - . .......--••--------z .... ............................ - - - - --
x
' U -
W
U 'Nature of Repairs or Alterations—Answer when applicable._______________----------------------------------------------------------------------------
------------- ------------------------------------------------ ----- ------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System lin 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 by the board of health
„..
Signed, :�' •--
a
Application Approved BY------- r ig' = '"�, ---------- ..4 - --�=
Dteate..,.,ems
Application Disapproved for the following reasons:-------•---------•--------------
--•••-••-•-•••••-•---•-••--......................................•-----------------------............................ -------------------------•-----------••----------------------------•-.........
' �,� � Date
PermitNo.................................................... Issued---t
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
X
.::.. ......
(Intif iratr of 011kilutphatta
THIS-IS TO CERTIFY, That the I dividWj Sewage Disposal System constructed ( 'or Repaired ( )
by FPS } ...............................................................................
- s Inst Ile'
at__••••............................. -- •=�-°-i- f "!'_,� '{-r--•`'"- '--=e-----�'`°.` ,.��." !a_.._+`'A..:._ :.d. C.r'' �.:._.---•--------------
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----- _'`e ___..... dated____.,,; _..___!.'________________
THE ISSUANCE Cr- THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM ILL FUNCTION ATISFACTORY. � ,
DATE - -` ---•--••---••-_-_.... Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
f E�
<.... s .. ....... f��.fs............. *. \,- f',•�.„�n J'I- S� f.... -'----------------------- ,{
No ... . FEE.......,.
___•-----
Uhiv o al YoI.rks %Tonstratrtioat, rruti
Permission is hereby granted -'-" 2•+ 1. `- •--- _E� ",er _-Y_ f �
to Construct or Repair ( ) an Individual Sewage Disposal System qp
Street
as shown on the application for Disposal Works Construction PermittNo. ____ Dated_ ............................
•--•-••-•••••--•-------••-_••--- -----------------•-----.__..__..--•--••••----_...�
Board of Health
DATE.................................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS