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Home My WebLink About0194 MITCHELL'S WAY - Health (2) q,H A))v�ck�eb� No.... .......... THE COMMONWEALTH OF MASSACHUSETTS QIL BOAR® OF HEALTH -I"i0/ . ✓....... oF.....�� 1s4S6G� .....-................................ •(Y Apphratinn for Diriposal Works Toust•rnrtinn runfit /lAplication is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ....Lo..1.'..:.....7........ .. ..�l�c ... .y... / .y ��s ........................................... ~ Location•Address or Lot No. ................... l..,K',e :, ..... . ./. ./..7..`..G.�.. . . .,........................ . ........... ................................................... Owner .//�� ,�� Address ..j �.......... (lc........ ... ... . . . ..................�....`......... ........... Installer Address UType of Building y �� Size Lot... ,�..............Sq. feet �. Dwelling—No. of Bedrooms....*................................•........Expansion Attic ( ) Garbage Grinder ( ) a'4 Other—T e of Building No. of persons............................ Showers —Type g ---------------------------- P ( ) — Cafeteria ( ) Other fixtures .................................. W Design Flow___f.'__ �2_--.__--•-----------gallons per person per day. Total daily flow........�.__�.:............gallons. 1:4 Septic Tank—,Liquid capacity&Aallons Length................ Width................ Diameter................ Depth................ xDisposal Trench—No...._..-. ..... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.___1J�d_ � Diameter.................... Depth below inlet.._................. Total leaching area..... .fG. ft. � �- �------ P g ' • ...� q• Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date.................. ..................... Test Pit No. 1................niinutes per inch Depth of Test Pit.................... Depth to ground water-------__.---_--__----_. rz-, Test Pit No. 2................minutes per inch Depth of Test Pit------_............. Depth to ground water........................ 04 .................................�_-_•..-.---,........- ----•----------------------------...._.•..--.----•---------------------- •------------------------•- ODescription of Soil........................ ..........................................................•--------------•---.................................•-••-•••--- x w -----------------------------------------------•------------------------------------------•--•----------------------------------------------------------------------------------------------------•..... 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—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of heal Signed. d.......................................rl� 7--3 .. . ..._. ....••••......._._ ................................ ` Date Application Approved By................ --- ----- -•------ -------•--•-•-••-••••-----------.................. ---•- Date Application Disapproved for the Bowing reason ...................••-------------•--------•---.............--•-------........................................ .............•-•-•----•-•--•.....--••-•-•.•••-------••-----........---•--••--•••--•......-•-•-••••••••••---•-•--•-•-•••-••------•-•--------------------••-•---•------••••-•......-•----_....._......... Date Permit No. ...................................... Issued------1 �1� Date ______- ------------------------------------------------------------� Fy No..... = - Fi �... .: :.:'.._..... THE COMMONWEALTH OF MASSACH-U�SETTS BOARD OF HEALTH _. r twit far 15ispoodAlurks Tutudrurt$jan Prruid Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ---- '.............../`, t................................r/1 �,A 1/ .........;1 . ................. s` �' s . ........... Location-Address or Lot No. s ! .................... .4,. O F` 1 ...c:. �'a .......................................................•.....__........_......................._.. W / > Owner Address/ .......... ._ r Installer w= a...�x^` r '*•�.vc' ,•��Address YP g k,-- Q Type of Building Sq. feetn Size Lot..__/�.�?�?. �... Dwelling—No. of Bedrooms..«............:...........................Expansion Attic ( ) Garbage Grinder ( ) 04 W Other—T e of Building ............. IV o. of persons............................ Showers • YP g ............... --.._._..._...P__. ( ) — Cafeteria ( ) dOther fixtures ..................•-------------•- ------------...----•-•......................... .._ ....._ Design Flow......_. .... ": gallons per person per day. Total daily flow......... ._r .............-...gallons. WSeptic Tank—Liquid capacity. Z4—'.1 gallons Length................'Width................ Diameter....:........... Depth---.-__------.:. x Disposal Trench—No.. ..._�,Y -.-Width.................... Total Length----------_......... Total leaching area....................sq. ft. See a e Pit No... 1> .:Diameter-----------------•-- Depth below inlet_._.............. Total leaching ft. P g P a area. 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........................ w Test Pit No. 2................irlinutes per inch Depth of Test Pit.................... Depth to ground water-_-_-_---__-••---.---_-- -----------------------------•---------------------.._...------------....................................................................................... O Description of.Soil................... x P „, `t=_.: ...,•._.. ............ ...._......------------......-------------------------------- . ----------------------- V ........................ ..••--•--•-------•............-•---•--........_......_.r .. .....-----•......••-•-------•••. W Z ---------------------------------------------------------------------------------- -------•----------------.._. .................................................................................... 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—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of heal Signed-- --- 1sry . x ._ t. d Y .... ....._.I`... ._.._........... - Date Application Approved BY -- ... .. ----------------------------------•-......----- ....---........ ,b- ------ l Date Application Disapproved for thel lowing reason -----•----•- --•-------- ....•--•-•...............•------•--•-•••---• -•--•-..... .................•---•----•---••---------.............----------...--•----••-•---•---.....---......-•---..........-•---•--------...--•--.................---•--.........--•-----••--•---••-•---••---••-- Date Permit No. `"� --•----- Issued .. `.... s f Date THE COMMONWEALTH OF MASSACHUSETTS., BOARD OF HEALTH .. OF...... . y,................................. ..�,,ai'a tee'�' �� f,�., �'..,��r✓ .�.�' ., THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed Or or Repaired ( ) �.. x tby I 7 r.. 'P"'yr r��y�•°Yt?^ �,"n •»tee_ r >� .S (¢ 1 "G.r `�. $.. z.•Cp°'7 �4r '�'-Y � ...................... has been in�t�l QVin acco4a"rice with the provisions of Article hI of girlie .state Sanitary Code as described in the application for Disposal Works Construction Permit'tio------_ ------ __- dated ................................ ......... THE ISSUANCE OF THIS CERTIFICATE SHALL WCON SiRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DAB E -F p[y� .;-----•-------------------------------:.-------- Inspestc r , •_ L ._.... ..._.__ ................................ :..r., ------- THE COMMONWEALTH OF MASSACHUSETTS � + BOARD OF. HEALTH r° ° ................. ... OF................ 'a�"" c {<�° r... ......... �J) P v No............ ... fi :�a fit.+ r'1 c"P A x. FEE • •............... R Permission is hereby granted............... { r` s a '¢ " to Construct ( ) or Repair ( ) all Ind1VI 1'Sewage Disposal Syst6h atNo.................... ............................. :: ... // = 1r'? L� ,} /r .* dr #fiheet y�f fX 7t`a a as shown on the application for Disposal Wonks Construction Permit `No.,-_-.,,.f ._._._ Dated-_--_____ _n__ .._... ...,. ... h --_.._-•••--•------------ - --- ----.__........_.............. D T `� } Board of health v _------.-.--.-- ----- ;t FORM 1255 'H BDS & RREN, INC.. PUBLISHERS