HomeMy WebLinkAbout0083 PEARL STREET - Health (2) UC1� d(j(
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.SY�.... Fps.. ................
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THE COMMONWEALTH OF MASSACHUSETTS j
V
BOARD OF HEALTH. '
....._..............................O F
/® .....-
ApplirFation for Disposal Works Tnnstrnrtion ramit
Application is hereby made for a.Permit to..Construct ( ) or Repair (�!) an Individual Sewage Disposal
System at• ��) S-
1... . .
D catjon- ess�� 'O e S or L6t No.
.... . C' 1 . ... ..... �., .� �..--••- .... .• ...................................................
/" I eft 1� d
Address
a O Jlcaner....................•••--........
..............
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
P4 Other fixtures ..................................
W 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..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by----------•-•-•--••-•-•••••-•••••-•••..............•••.....----•---------- Date........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit.__.__....._........ Depth to ground water........................
fT Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ----------------------------------------------------------------------------------------
----•-- ------• -•----•- ......•-••... ---------
•---------
0 Description of Soil--------•-----•---..•..-•.................................................•-•---------------•----------•---.........----------------.....----••-••••••••••....._._...---
W •---•-•--•-••---------------------•-•-••---•••-••••-----•-----••••••-•--••-••-•••••••••.........-••---•-•----•••-----•----••••---------
V Nature of Repairs or Alterations—Answer when applicable.-l� /r f� _..�../. .. �1 .._.....
----•••--•••-•-•••........................••--•••••••••••••••--•••••-----••-•............-•--•-••--••••••-••-•-•--------••-•----•••••-....------....•--•-•••-•••••-•-••--•-•......---•-•--•---....---••-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT I.Y'. 5 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)wealth.
Si ......... ............ .. . ..... ...................... �Vv-7
`� Date
Application Approved By.................... ` / ----------------------------- ---••-•Fly-•-- •�
Date
Application Disapproved for the following reasons:...............
........................•----_. •---•••--•-••.
.........................•-------•-•-----............--•----•-------•---------•------•-•---••-------------------••--•......•--•--••-------------•••-•---•-•-•--••••-••-•••--••-• .......................
Date
PermitNo.......................................................- Issued_•-2•-•••••-• --••-...........................
Date
No:: » ..» FEs-. .................
_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
------...... ........................o F "� .,` Y .. ...................................
Appliration for Dispog al Works Ton,otrnrtiun ramit
Application is hereby made for a Permit to Construct ( ) or Repair (�) an Individual Sewage Disposal
` . System at
.......... -.�f-- '-�r' . - -------------------------------------- ----•- -------------•----------_-_-__ ___---•-•--------- ----. -_--•-
i, Lpca on ess f or Lot No. - ����
.�».._ '. ._... ...........................t ..�►�.�.!_. .. ���---/a�'�---!_-----
Address
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms................................ _Expansion Attic ( ) Garbage Grinder ( )
~ Other—Type T e of Building ____________________________ No. of ersons____.__._.__.______.__._._._ Showers —
p�,, yp g p ( ) Cafeteria ( )
Pa Other fixtures _..--------••---•---------•-•----••-•---•-••-•-
W Design Flow............................................gallons per person per day. Total daily flow......................._....................gallons.
W Septic Tank-Liquid capacity............gallons Length................ Width.......,........ Diameter................ Depth................
x Disposal 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 ( )
Percolation Test Results Performed by................................. ....................................... Date........................................
a
Test Pit No. 1________________minutes per inch, .Depth of Test Pit.................... Depth to ground water........................
f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a+ ............................................................................................................................................................
ODescription of Soil........................................................................................................................................................................
x
V ------------------------
•------
.... ------------------------------------------
•••-----------------------------------------------------------------------
•••---------------------------
---------------
•---••-------------•----.....-----•-•-•-------•----...-•---•---------•-••-•••---•••-••••------.---•- ••- '
,,tt
V Nature of Repairs or Alterations—Answer when applicable..�?�• _ P ._l_ ...� ° _4- ---------- .
------•-------------------•--••-•---.._.__...-•--•-•----••-•--------•---._..._...._.......--------•----•--•-•...••••-----••-•-••--••••-•-•--•-••_...•-•--•-•---•-•---•••--•••--•-•-••-•-..............
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issu dd by the board of�ealth.
Date
ApplicationApproved By..................................................................................................
Date
Application Disapproved for the following reasons:_______•______________________________________________________________________________________________________»
••-•--•-•••--••--•-•-••--•---•-•------•••---•-•----...••••••••-•-•--•-•-•--._...•••••--••-•--•--•--•-•---'•---•-•-••--•-••-•••-••--•-•••••-•••••---•----•--••-•--------•-••------.... --••--•-------
Date
PermitNo.......................................................» Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF./ " ' J'...'��
TrrtifirFatr of TumpliFanrr
THIS IS ER�a,IFY, That e Individual Sewage Disposal System constructed ( ) or Repaired ')
by---------------------- ...C-.2L.,----�--•------= 0--------------------------------------------..__....------------------------------------------------------------...----------
! Installer
at.-•---- -a--------- .; _ ......_......'--'....---------- ` r -------------- •------•---•-------------....--- '-------------= ...............................
has been installed in accordance with the provisions of TIC j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.___ , .r{ "'e________ dated------ ...........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..........................:....................•----•-•--.............•--...--_. Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�)/
G
✓No ............. FEE.___-:..................
Diapo 1 orku Tunstrnctuan rrmit
Permission is hereby granted... _._ ............................................
to Construct (' � epair (.?) an In ividual S . rag Disposal System
at No.____ �
Street
as shown on the application for Disposal Works Construction Permit '..�-
� D De
Board of Health
DATE.......
(�.._.. -----------------------------------------
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS