HomeMy WebLinkAbout0026 PAWNEE COURT - Health (2) 2l� Pcwn-eta
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD O�l�� H
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Appliration for Roposal Works Tonstrurtion Prrmil
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
Syst at:
ocation- dr ss Lot No.
Y . �.-- - ---- -- ----------------'-------------- r ----------------------------------------------
Owner > ddress
Installer Address
QType of Building- Size Lot____________________________Sq. feet
U Dwelling No. of Bedrooms............
............................Expansion Attic ( ) Garbage Grinder ( )
`4 Other—T e of Building No. of persons____________________________ Showers — Cafeteria
a' Other fixtures ......................................................
-----------
Design Flow___ ____________________ ________gallons per person per day. Total daily flow____._______.._.gallons.
WSeptic Tank Liquid capacity............gallons Length................ Width---------------- Diameter---------------- Depth_____________.-.
x Disposal Trench—No_____________________ Width_......_. .......... Total Length.........._________ Total leaching area--------------------sq. ft.
Seepage Pit No.-I---------------- Diameter_l __ Depth below inlet........ ..... Total leaching area..3 ._(�//_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-_-__________________
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 --------- ------ ------ ------------•-•--••--••••-•.....---•---------••--•-••-•-•-•--•-••-•-•-•-•-••--•••••--••-------••-------------------------------
O Description of Soil________________
U -•-------------------------------------------------------- -------•--------------------------------------------------------------------------------------------------------------------
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 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.
Signe
-
Dat
-------------APPlication Approved BY 6 -L e
"
- Date
Application Disapproved for the following reasons:............................ -------•----------------------•.----------•-•------------Da.••-----•••--••-
•-•--•--•-----•-••••••••••••-••••••...............•--------•••••--•------•-••••-•--•----•=-----------------------•--------------------------------------------------• -•----•---------------------------
Date
PermitNo......................................................... Issued........................................................
Date
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD JO H�
..........OF..... ......
AVVI r.Afton for Uiiposal Works ..Tomitrurtiou Prru.it
Application is hereby made for a Permit to Construct <✓ ) or Repair ( ) an Individual .Sewage Disposal
Syst at: r
Location ddFess , I r Lot No
Owner ddress
_
Installer , Address
Q Type of Buildin Size Lot--,.........................Sq. feet
U Dwelling No. of •Bedrooms.._____-__'....:......... .....Expansion Attic ( ) Garbage Grinder ( )
,
a Other—,: Type of Building --------------.............. No. of persons................
------------ Showers (`. ) — Cafeteria ( )
s, Other fixtures ;_ = ---------•----•---
W
Design Flow... ...................1 ........gallons per person per day. Total daily flow............. :_.: --.-._gallons.
WSeptic Tank Liquid capacity----,-------gallons Length................ Width----------------_-Diameter.;--------------- Depth_-.----_---._.-.
x Disposal Trench—No...................:.'Width.................... Total Length-----------_,_,,_ Total leaching area--------------------sq. it.
Seepage Pit iNo./................. Diameter/ .._. Depth below inlet...... ---- Total leaching areaeg-&-sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed bY--------------------------------------------------------------------------- Date----------------------------------------
W per inch Depth of Test Pit
Test Pit No. 1____;�;,,. minutes p p .................... Depth to ground water_______________.._.___.
(� Test Pit No. 2.................minutes per inch_ Depth- of Test Pit____________________ Depth to ground water------------------------
- -- ------------------•-•---------------------------------••-•-•--•---•--------••---•---•-•--•-•-•-••-----------•----•-•-----•-
O
Description of Soil---------------- _ - ;----:..--•------------------------------------------------------------.....-----------------------------------------------...---
x
V .---------------------------•------•---•-•-•-•--•----•••- °
W
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 by the board of health.
Sign
Application Approved B D t _
-- ..................
' � '. Date r
0
Application Disapproved for the following reasons-........................
-----------------•- --------------------------•• -------------------•-••-------. -.-...-..........
.........................................-------------•--- -.....•--•----------------------------------.._.._•--•---------------•-----••-••----•-------------------•--------------..._......--••-----•-
Date
PermitNo.............................................................. Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD, OF HEALTH
•
10
..........OF....... .2
9rdifiratr of-Tomptiaztrr
TH IS O C R 'I Y, Tl t the Individual Sewage Disposal System constructed O or Repaired ( )
by � " --------------------
. =
at � I staller r
has been installed in accordance with the'provisions of ArticleI.of The State Sanitaiv de s desc ibed in the
P
application for Disposal Works Construction Permit No.................... _ ......
dated__. _ r. '_ "y
THE ISSUANCE OF THIS CERTIFICATE 'SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE --------•--•--•---------• Inspector--- -• ------- _ ..................
--- �.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�� + ....O F.........
l ! ., _.. .......... �y
No. --- ... - FEE--c
QT
Permission 1sehereby granted.......................................... ...........
-----------------------------------------------------
to Construe ( )�,orr Rea ( ) ,an Indiv eljal--S6wa e�Disposal
at No. ^^- '` �t " T ` C°'...F_ ./ - - ---------------_----
_ _.
istri rt
as shown on the application for Disposal Works Construction -ergiit NO. Dated-__ "' -- -- ----� _
3 � ---- ---- - •--•-------------_
Board of Healtli
._DATE.....
FORM 1255 OBBS & WARREN. INC.. PUBLISHERS
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