HomeMy WebLinkAbout0177 PLEASANT STREET - Health�1� ���o�
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_No..-•---...Z..�......... ��O .......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
d.lv Vie,!.......OF...... •�I ST�f•bC ......----------------------------------•....
, ppfiratio t for Dtspizal Works Tonstr tr$ion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System,at, /
Locati Addor
r s v .............................................Lot No.
Owner Address
a -----------------.................................. •----•-•---------------- -------------------•--•--------------------
Installer Address
Type of Building Size Lot............................Sq. feet
U arba e Grinder
(Dwelling—No. of Bedrooms.........................�- Ex Expansion Attic G )
1.4
p.., Other—Type of Building of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ----•-•-------- -----------------------------
W Design Flow............................................gallons per person per day. Total daily flow__l_ .. . ......_......__._._gallons.
WSeptic Tank—Liquid capacit lf�-_gallons Length---------------- Width................. Diameter................ Depth................
x Disposal Trench—No..___-•_•.-_._------- Width.................... Total Length.................... Total leaching areal_ 0_0 0--_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....Ch Gl ---............................................. Date........................................
aTest Pit No. 1.....ol .._..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-_--___._-_____-__-____.
....
•_-----------•--•-•-•---------••----------------•--•----•---•-----•------------------------•--••---------•---------------
O Description of
U -•---------•-•---••-•••••-••••-•--•-•---------•---...-•••-••--••-••-•--•---•--------•••--•----•-•--••-•-•-•-••--------••--••----••••----••••--••--•••--••--••-••••------•...-•••--•--•-•-•-•-----.......
.......... ............. ..........•----------------------------------.......----------•-----------------------------�V a r-------- ---
U Nature of Repairs or Alterations—Answer when applicable........________________ _________________
A.Cr���/` _ .......................................................................
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 iss by the board of h.
Signed-- T . — . 7y
Date
1
Application Approved By.......... ---�-•-...........
Date
Application Disapproved for Vielfollowing reasons----- ...........................................................................................................
----------------------
-----------------------------------
-----------------------------------------
........--------
•--------------------------------
•-----------
------------
•-----------
-7 Date
Permit No..........J.... ..,. �`�x' 7L
----------------•••--•-•..-----.. Issued f
Date
No..........71:....... F�s..... �..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
10'---..._..----PKAP u.........OF.....+*............................. ,.
Appliratiun for Ropatiat Var.ks Tonstrur#ion Frrmit
j,
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
............ ° ...... ------------------------•--•---...... --------------.....------..........------.
Locati ddr s or Lot No
Owner Address
Installer Address
Q Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms........................ Expansion.Attic ( ) Garbage Grinder ( }
PL4 Other—Type of Building ,�(�f ! _ To. of ersons____________________________ Showers — ( )
a g - p ( ) Cafeteria
Otherfixtures ----•-••---••-•-----•---------------•--•-••-•-•---•-=--------•.........------------......•••••- -----•---
W Design Flow..........................:..... .....::..gallons per person per day. Total daily flow__;1!,011_�_.__ ...................gallons.
WSeptic Tank—Liquid capacit�:_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
�..,, C'/7 ,�r z �t�R
Percolation Test Results Performed by.... ............................. Date Date---------------•-_-_--------....-•-___--
a .Minutes per inch ,-Depth of Test Pit____________________ Depth to ground water_________._.______._._..
Test Pit No. 1__:__:�____. •
Gz, Test Pit No. 2................miltes per mch Depth.of Test Pit Depth to ground water _.__..__.
%
O Description of Soil___L_c,Cf 3�"_.J 4. ......... _ •
x ------. .._•---• ---•-- --•-- .
----------------------------------------------•---•- ............................
... -••---• ti
V Nature of Repairs or Alterations IL-
: 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 issupd by the board o h.
✓' - 7`-1
Signed•-• ��!T - .... •. ----•-
Application A roved B I'�. . G�f'4 / a
PP Y :: ---- ---•• -----------
--•-----
6,' Date
Application Disapproved for t ie following reasons:•-••-------------•-----------------------•------ .........................................................
.......--••----------------•--•----••----.....---..---•-•---••----•-•-•-----•----------......------------.._-----•-•-----•--•-------------------•-•--•----------••---•--•--------•-----••---------•----•-
,�1 /� ate
Permit No. - ..r Issued -�-•� ---•._._. ......... _:.
Date
-t
�••�� , �'�iu-. � 4 .....r ten... t,. 'e�n r: ,7�
THE COMMONWEALTH 6'#� fASSACHUSETTS
BOARDf OF HEALTH
DGu Gal.........OF.....
Cnetifiratr of
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
bY--•--•--•---•---•--•-C"90Ati D +S--••-�-----
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 I�jo _..7 ,:=s_______________________ dated------ _. ^___ _____....
THE ISSUANCE OF THIMS'CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....... -•--- Inspector..
-----•--•-•-•........................
THE COMMONWF�ALTH OF MASSACHUSETTS
BOARD OF` HEALTH
No `1............ ; FED.... .'
Permission is hereby granted.......ClIgA!A."ap.s___-r._..------------•-•--...................
..,....
to Construct ( ) or Repair ( an Individual Sewagespos System
as shown on thepplcat3ora fr D.sposal Worlcs Coristr�tcton.Perinit`'No `+ .__....... Dated..... ........
41
. _ __..• -•----•-.
'�,(jf Boar of Health
ft
FORM 1255 HOBB§-& WARREN, INC., PUBLISHERS M -
w�� s»bM-aeu".r+ '•*-�:,.iya.. ' * ,.ke,r„pd.� `J i .
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