HomeMy WebLinkAbout0160 ROSARY LANE - Health (2) l�� R� �l�-��
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THE COMMONWEALTH OF MASSACHUSETTS.
BOARD .(? HEALTH
ItV. ....V�C�.............OF.......... ...............
ppliration for Disposal Words Tons ion Primit
pplication is hereby made for a Permit to Construct or Repair ( ) an Individual ewage Disposal
Sys I t•( Q yj
... .. .. .......j.. .....
o .on-Address `� or two.
Owner Address
n 11er Address
Type of Buil in '
Size Lot------------------ -------Sq. feet
Dwelli No. of Bedroo s___'_...__. Expansion Attic .( ) Garbage Grinder
Other e of Buildingo. of ersons..'�........ :' Showers .( ) — Cafeteria ( )
Other fixtur - --- - -------- ----------------------------------------------
•--.---------------------------
-----------
WW Design Flow ___________ ____ _. allons per person per day. Total daily flow............................................gallons.
WSeptic Tank Liquid capacitallons Length---------------- Width. Diameter................ Depth................
Disposal Trench—N _____________________ VVi th__..____ Otalh___ Total leaching area....................sq.;ft:
Seepage Pit No...... ----.-_-- Diamete // --_-" ep b �w In et___________________ Total leaching area.......-..........sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by......................................................................... Date..........................................
Test Pit No. 1............:...minutes per inch Depth of Test Pit.................... Depth to ground water........................
4., Test Pit No. 2................minutes p inch De th of Test Pit............._...... Depth to ground water........................
[�
Description of Soil.....................
--•------------------------•-------------------.----•-... _
V --------------------------- -------- .::
W ----------------------------------------------------------------------------•-•------------------:-- -----•------. -------------•--••--- .----- .
UNature of Repairs or Alterations—Answer when applicable _. ...................................
•--------------•--------------••-------•------------------•---------•-•-•----•----•--••--•-•-= ............................ ---•----------------------------------------.•----.------•----••-•-
Agreement: . 1
The undersigned agrees to install the aforedescribed'--Jndividual SewallDisposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The-undersigned further r„ees not to pl ce the system in
operation until a Certificate of Compliance has been issued by the board of h
Sign- _ .
ater
Application Approved By...-- ................... ..�-.----- .1 ...
Date
Application Disapproved for the following reasons:----•...........................V--------------------.........-----------------------------------------•.
...................................................--........._............._._.......... Y. ...____..............______•___ ......_._• ________ _....._____.______••_•_._•__•__•
Permit No.._.. .... , Issued= F
--------- --------- -- -----
No. 0 L... FEE• ....
THE COMMONWEALTH OF MASSSACHUSETTS� b
BOARD (? H.EALTH i
oe
.........OF..........
A firation 'for*Dispotial Works Tonstrttdion prrntit \
3>>• Application is hereby made for a Permit to Construct ( or Repair ( )'an Individual Sewage Disposal
System
................................
oci ion-Address r, t'jj/�jo
Owner Address46�
(v' f
..;
pq xis, er Address
' : ¢ TYPe of Buil in Size Lot............................Sq: feet
V Dwell'iV�:�pe
NO. Of Bedroo s.__. Expansion . ttic ( ) Garbage Grinder ( )U
pa, Other of BuildingL44to. of persons_� "�"..... Showers ( ) Cafeteria ( )
I` QI = Other fixtures ........
W Design Flow .:..... :....: a11onS`per person per day. Total daily flow......' gallons.
WSeptic Tank-Liquid capacitallons Length________________ Width, :_ ._._:Diameter :_____ Depth................
Disposal Trench N __________________ Width__._ 'Total h , Total leaching area.__._______________sq. ft.
Seepage Pit-No. Diamete rbtf a -...._ Total leaching area.....=............sq. ft.
-
Z Other Distribution
d tank
rmed by.._* ( .PercolationTst Results Perfo .. Date,`^
--.......................... .
a Test Pit-No. 1.................minutes.per,inch Depth of Test Pit ................. Depth to ground-Water.........._............
rZ4 Test Pit No. 2................minutesth.,of Test Pit........._---------- Depth to ground water........................
LYi r
•
Description of Soil----..•-••........... . ....... ---••-------•---- --7----- ......----•-------. •..................:....-•-•----•
W .............................. ..... ... .. ....... ..................... ................................
__________________________________________________________________________________________________________________
r
U Nature of Repairs or Alterations—Answer when applicable..........
. ... ...............
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage.Disposal System in accoi,dance 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 h h.
� __ ......--•-•- ..--`-•---------•-. fir,
D t
Application Approved
Date i
Application Disapproved fo'r the following refisons:_ ... ._ -. 5.........................................
�`eayyi's yet
5
............................................................................. ....a •
-•- - -----------------••-----ate--
�' f `
Permit No........................................... -°A.. `.. Issued--------.-- - ... ---� -----•----•----
- •� •, - � Date
THE COMMONWEALTH OF MASSACHUSETTS' -?
BOARD HEAL.T
.........OF..... . ... ................
Trdi$irat of (lam iattre
S S TO TIFY, That the Individual' Sewage Disposal System constructed ( ) or Repaired ( )
b ---• --
, ,:.... .
Installer
at._-+ .... //J�//�/j��{ jjj7 � ✓ Imo° Jy�$/�
has been installed ccordance.:fw`lth�the provision of Article X 'of The State Sanitary Code e ribed in the
application for Disposal"Works Construction Permit No...........__ ,c•__°�-------- dated......"'�' ...j/
THE ISSUANCE OF THIS CERTIFICATE`SHALL NOT BE CONSTRUE® AS A GU77
ARANTEE THAT THE
SYSTEAA �6U L FU N TION SATISFACTORY.
1.----- Inspector--.DATE.` l �? �0 -- ..................
/�........ .......
- -
-> THE COMMONWEALTH OF MASSACHUSETTS
BOARD OA., "HE
.. OF. 1!
/
No.....i Z. FEE...!)..` �
14spos on onstrtdion amii �tk
Permission is reby granted.......... r _..:...----•-------•-••...:.......:................... .::..... ;
dual Se D' yst
at No.._ ( Repair �.__...._. � �,,
to Con ua o R a>.r an Indiyi�� - - •. �,Y . •
.. 4` ' treet 6iKj,E "
as shown on the application for Disposal Works Cons ruction mit N ..::: _ Dated...-X..lj__ ._.7 0
� DATE__..:!,! T �
~. J FORM' 1255 HOBBS & WARREN, INC., PUBLISHERS
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GEORGE
FRANCIS
REEKIE
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