HomeMy WebLinkAbout0110 ROSARY LANE - Health (5) � � � � ���
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E COMMONWEALTH OF-MASSACHUSETTS
BOARD OP HEALTLi
OF....... ..........
Appliratinn -fear 11iiV a ml Workii .Towitrurtion Vrrmit
Application is hereby made r a Permit t oCQnstKuct (04"*)7or Repair ( ) an Individual Sewage Disposal
Syst
-. ----•---• ---- ------- ......... .......... y,s--
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Loca on-Addr or Lot IVo.
r -- . .. ........... .......................................... .--"-""-•----.........._..._.........._...--
ne Address
-r -----------------------------------------------------------------------
taller Address
d Type of Buildi Size Lot----------------------------Sq. feet
U Dwelling o. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
P-1-, Other—Type of Building --------------------------"- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a Other fist L .. -- - ------ --------------_
d ---------- -----------------------------------------------------------
- ----- -- ---
W Design Flow. ............................. .. Mons per person per day. Total daily flow----- _...... ------ __-_----.--.-.-gallons.
WSeptic Tank Liquid capacit}/-Tons Length-------------_ Width................. Diameter-- ---------- Deptll._-___.-.._....
x Disposal Trench—N . -.----_. --- .-__- Wid li._.. 4--- tal Le th--_--" .._..._ Total leaching area--------------------sq. ft.
Seepage Pit No_________ _________ Diameter.)..t __ i Total leaching are a.------_---------sq. it.
Z Other Distribution ox ( ) Dosing tank ( )
aPercolation Test Results Performed by-------- ----------------------------------------------------------------- Date----------
,� Test Pit No. 1----------------minutes per inch Depth f "Pest Pit.................... Depth to ground water.---- _.. ....
Test Pit No. 2................minutes per inch Dep of Test Pit. --..----________- Depth to ground water------------------------
x -----------------------` ...........................................................................
0 Description of Soil-------------------------------------------------------"--------"------------------------------------------------------------------.-----------------------------------
x
------------- ------------------------------------------------------------------------- ----------------------------- ---------------------- --------------------------------- ---------------------
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 tI of the State Sanitary Co _10,e undenle
r agrees not to place the system in
operation until a Certificate of Compliance has be s y t oigne .----- --• �- -----" -----------•-------
-- -
Dat c,
Application Approved By---- " -------------------
Date
Application Disapproved for the following reasons:.........................---------------- -.......------------....----------------
-----------"---------- -"---" - ---"-----••---• - ---- a- ..............
• ' Date
PermitNo......................................................... Issued...'. 1 --�-_
Date f , _^
No...... / Fs$........... .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O1 HEALTH
�L7----OF........:6C�1�,--Grl-' -C _.... � *..i '
1
Applirtttion -for Bi_qpoiial Workii Tonstrurtion Prrutit
Application is hereby made for a Permit to Construct (% ) or Repair ( ) an .Individual Sewage Disposal
System-at: � _
Location_Address0 f f/ or Lot No.
4 "1......................... ..............fi......_.v..__..._._.__......_..._..._......._ ..._............_..._._.__......................_........._.............._._....._.._.........____
1 Owner Address
- v----------•---------------�- y
Installer
--•---- _ Address
Type of Building/ Size Lot----------------------------Sq. feet
U Dwelling—t,/N0. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures . --------------------------------------------------------------- '----------------- I.....---------------------
W Design Flow.....................' _..__. __.__._gallons per person per day: Total daily flow......._'_....`_ J............gallons.
WSeptic Tank-L Liquid capacity,./.!gallons Length................ Width__.-..__.__._ Diameter---------------- Depth...........__...
x Disposal Trench—No_ ____________________ Width.......:------ __!Total Length-------X......Y. Total leaching area-_.__.______..._____sq. ft.
Seepage Pit No._._._.._�__._._____ Diameter_. __---..-_.-Depths belo"W inlet ...... .. Total leaching area__________________sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by------- ----------------------------------------------------- -------- Date---------------------------------
Test Pit No. 1................minutes per inch Depth of "Pest Pit-------------------- Depth to ground water..-__-
Lz Test`Pit No. 2................minutes per inch Depth,of Test Pit.i................ Depth to ground water..._..__-____-_..____._.
X�!f --•------------ --------
ODescription of'Soil-----------------------------------------------------._..................... --..-..--------------------------------------------------------------------------------
x
W ------------------------------------- ---------- ------------------------------------------------------------------------------------------------:..._...----------•------ ---------------------------
UNature 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'furtlier agrees not to place the system in
operation until a Certificate of Compliance has beensissued by the board of health.
,�ft(✓1
/�
/1 Date ?
Application Approved BY = '.=..........................................r.......' .y ........i.7 ---•D/--�-.
ate
Application Disapproved for the following reasons:--•---...--•-----...--•-•--------------------'----•---••---•-•---•-----•-•-•----.._....------------•--•-•-----
......................•----••----------------------------------•---------------------••-----------•---•------------------------••----------------------------------------------------------• .........
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O�HEALTH
�...... : - ?A.....OF........... ....7.r���sx.!��ii-..........
1011rrtifirttte of f1-11Dtritpliatta
THIS IS TO CERTIFY,L`That the Individual Sewage Disposal System constructed ( l') or Repaired ( )
/ x' r
b a�.I/ ��-� +`rt.. r .-..-__�.�.* --..............._--...._......._.._._....----•-••---•------•. --------------------------------.............
Installer
at----•-------�• "-- � -t_�+/ / /� ---/L2- if / !r tti//..!_r[/
_.. ` �.. _
has been installed in accorda ce with the provisions of !Article XI of The State Sanitary Code asdescribed in the
application for Disposal Works Construction Permit No...__...._7_�-__�-?__r_----------- dated_.__-//----------`---------__ ...........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL F U- TIO SATISFACTORY.
DATE..........`0 /� 7 --------•-------•----------- Inspector.......... ...............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........OF.. ....................................................... Y"f
No.--- -,"'=------ FEE... ----•-•----
�i�'���ttl� �rk,� C���t�tr�trtilait �rrtttit
Permission is hereby granted____h� ..... t
to Constructs(�or Repair( ) an Individual Sewage Di osa�em \ /
at No.. /r./s /� / -, /,1� /1l � �,, �--r !!. �!.a :✓J
---------- ----- - -- ...� / -- ------- -_-
as shown on the application wJ
V / � I7 Street,
�'�
pp cation for Disposal Works Construction Permit No._--_______ _
" r - -' - - Dated---'---f�,r�is;..__.�>_.�-......
DATE----! Board of Health
--�--- ••-�a--r- ---Z -•.................•
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
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