HomeMy WebLinkAbout0052 PITCHER'S WAY - Health (2) 5� (5,i7r he s
4
No... .•... Flcn ........�.�.
THE COMMONW A H`�OF MASSACHUSETTS
BOAR® O HEALTH
�. 1 4,.........OF.......... .. ✓t—= '
Appliration for 'Dispasal Works Tonstrudion jUrrutit
Application is hereby mad for a Permit to Construct ( ) or Repair ( ) Individual Sewage Disposal
System
s
D . ............ .. .......... ..... .: ----• .......r....... .. --- •--- .....-........ •--•- - •---�--......... ..........
Location- s r Lot Wo. L .....
Owner Address
...... ..... ..... .� ....., ............• ........................................................
I staller Address
Type of Buildin Size Lot Z$ ._ q. feet
aDwelling o. of Bedrooms............. .............................Expansion Attic ( ) Gage Grinder ( )
pI Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
P4 Other fixtures ja--•- --------•---•----•--•----------•---•----------------•-----•-•---••--•-----------••-• �(�
--------- ....................
Design Flow..........:..........: "alloner person per day. Total daily flow..__.__ _....�...._._..°_gallons.
WSeptic Tank k Liquid capacity___. Length________________ Width-_-_-_____..____ Diameter....____.___.... Depth__-____--__--___
----- Wi th--- L nQth.................... otal leachin area---------------_--_s ft.
x Disposal Trench—N................ a g q.
Seepage Pit No ..... Diameter. .__._ p 1 ow i'&t....... ........ . Tot 1 leaching area........_.._ ....sq. ft.
z Other Distribution box ( ) Dosing tank ( ) v�� '�„�
aPercolation Test Results Performed by.....................................................................f-- Date .................................... .
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Gz, Test Pit No. 2................minute per inch epth of Test Pit.................... Depth to ground water........................
O Description of Soil.............. � --.��. ............... ... ..................................................
:. -•- �•/
U .•-•---------•.............................................•-••--•-• ------......._•.�---- _:_-:::::_: :::::::
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 ndersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued b board of eaI
igned-• -• ---- -- - - ------------------- --- ...
ate _D
Application Approved By..
•............. ... '-- .... ate- ---
Application Disapproved for the following reasons-----------------------------------:--- ----....-•-•---•-•--•••••---._......-•-•---------••------••--•-•----•••-
.......-•••--•-------•-------•-•--•----•..............•---•-•--•---•--....._.......---------------•-------•--•-•----------------------------•---...-•-•------•-•---•-•----•-•-•-•-•-•-•-•-•...-•-•------
Date
PermitNo......................................................... Issued........................................................
Date
.. ............. ............................................ ................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF -HEALTH
....... ... .��i ..........O F................ . ... ... ....................
T I TO TIFY, That ,the ndivZia,
l Sf wage�Dispa al ystem ctructed or Repaired ( )
y' -
Installer
at...... .••. ---....•.... ...A.�-•- ........ ---- ._ _.. :.
has been installed in accordance with the provisions of Article ._ he State anitary Code as described in the
application for Disposal Works Construction Permit No... .
------• { dated l'Z _ .............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. _
DATE----------------•------------•-----•--------•---•------•----•-••-----•--••----.. Inspector.....................................................................................
No ....(..!:. FE$ .....�...
THE COMMONWEALTH OF MASSACHUSETTS
SOARD O, HEALTH
Appli.ration for Dispasal Worho Toasts ion Frrmit
Application is hereby.mad for a Permit to Construct ( ) or Repair ( ) Individual Sewage Disposal
System
.. Locationd s or Lot Wt.
........ ---------•--
✓/� Owner yr Address
W ----•--• -. --•------- - .. ._ ..... lch-_/'.:7.....""'"� -- �•-`-'mac-=ZL_66r....................................... ......... ............
' staller Address
d Type of Buildm Size Lot_"_� ,;, q. feet
aDwelling- o. of Bedrooms........ ...........................Expansion Attic ( ) Garbage Grinder ( )
p 1 Other—Type.of Building .......................... No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fix res
---•-•-------•--------•-....------•-----•--•---•----•-•----••-•--•-----•-•-•.•-•--
Design Flow allo er person per day. Total daily flow «, ar� - gallons.
W ----•
WSeptic Tan Liquid'capacit k- y a Ions Length................ Width................ Diameter................ Depth................
x Disposal Trench N Width., ngth -----. Total leaching area....................sq. ft.
3 Seepage'Pit No _____ ___________ Diameter_ __ f�i ow in ........ Tot 1 leaching area sq. ft.
Z Other Distribution box ( ) Dosing tank
a Percolation Test Results Performed by_____ ................................................ Date-- -------- -------- -•---- .
,.� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
Test Pit No. 2................minute per inch epth of Test Pit.................... Depth t ground water........_---------------
- -----------------------------------------•..........
Description of Soil----••--•--- � - ': ... . ... .. ..----
--- . .. •-•-•--- --------------- ------
W .....::::::...:...::...:::::.:::.::.:::......:....:.::.......:.:.•:-•......................• ---._.. _,...... ' ---------.......................................................
UNature of Repairs or Alterations—Answer when applicable.__=___•________________________________________________________________________________________
a
----------------------------------------•------•-----••-•---•--------------------------•----•---•-------=---•--•-----.......--------------------------------------------------------._...........•-•-•-
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 ndersigned further agrees not to place the system in
operation until'a Certificate of Compliance has been issued by board of ealth:
igned ���yt . ..��......• -�0.1�-
c - -• ate -...
Application Approved By.. -• •. II--
- . .. � ate
Application Disapproved for the following reasons------- ------------------=---- -- --------------------------.............................................
. ..........................•-••---•••-••------•--------•-•--•--•-•---••-•-•------------•-.............-•--•-•--•-•----•----•---•----•-•-•---••--------------••--------------•---•---------------•------•-
Date
PermitNo.......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................O F...............................................:...:.................................
Mer#ifiarFa#e tit Toutpliaurr
THIS IS TO CERTIFY, That th ndlvldual S wag�Dispo�sal System coKfstructed ( ) or Repaired ( )
by...... -- ... - •�.-: ......../L64�---��,1 .��!1,=e ms.....................................................
--...
Installer ,
at..................................................................................................-••-------•--•---•--------------------------••--•----•-----------•------•--•-....----••-----•-----
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......................................... 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
..........................................OF.....................................................................................
No......................... FEE........................
Permission is hereby granted__ --------- ---------
to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst
atNo...............................................................................................................................................................................................
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated...........................................
......... -•••------••••-•--•-•-•.•--• -•-••--•--•-------•-----•-----•--.....-•-••---........-•.--...
/7
1 Board of Health
DATE eft// j-•---------------------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISPERS