HomeMy WebLinkAbout0047 SEAGATE LANE - Health (2) u�� - ayq� �4�
7
� ..............
a
THE COMMONWEALTH OF Ts
QJF HEALTH
.............. OF......... . •.......... .. �.
Applira#ion for DWposal Works Tonstrur#ivxt Pumit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Systemat:/...... . ._� ..... .--.-(y ...--- • .... ................................,
• Location-A dr or Lot No.
e �e
Owner Address
..........
Installer Address
Type of Buildi�� Size Lot............................Sq. feet
Dwelling " No. of Bedrooms.... .-..-----•------ -------Expansion Attic ( ) Garbage Grinder ( )
P4 Other—T e of Building ............................ No. of persons............................ Showers — Cafeteria
Q' Other fixtures. ---•---------------------•-•--•-••-.. . ._ _. . _
Design Flow........................ 1 .. . ......gallons per person per day. Total daily flow..._._._... gallons.
04 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter.......:........ Depth................
Disposal Trench—NO:..................... Width.............._... Total Length Total leaching area__._._..............s . it.
P � g q
Seepage Pit No--------------------- Diameter.................... Depth below 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 Test Pit.................... Depth to ground water_______________-___._--.
Test Pit No. 2........:.......minutes per inch Depth of Test Pit............ Depth to ground water........................
.......... ------------ ---- ---------------- ------------
Descriptionof Soil............. --• -•--• -�•-- -- •.t•----•--••-••-•---•••--•---•-•••-----••---......---•---••-----------•---.
x
W
U 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 XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been '•sued by the board of health.
Signe .... �"�
/at-,
Application Approved BY----• ....... -----
Application Disapproved for the following reasons:...................................
--•---•--.......--••-------------------------------------------------------•---••----•---•---------.......-----------......•-'---•---•--------•-••-•---.. .............................................
Date
PermitNo......................................................... Issued.,,.. .- ----....... ��``...........
Da
1
No... ;_1 !_..__._. F$$.. ..................
THE COI'vIMONWEALTH OF MASSACHUSETTS
BOAR® O� HEALTH
Apphr tiou for 11apaskil Workii Toustrurtitin - gr it
Application is hereby made for a Permit to Construct ( ) or Repair ( , ) an Individual Sewage Disposal
Systererp at
40
..--y ,-�. -Y' __T'.Y .._w._n�.+� 'Y:.Fs�. h.... 'vr- c ..... ,.-,4e.. 'RSJ,. :_• _• •••'_ a. ------ . ...................
Loc, ion A re m by ✓ or Lot N
•Y8•.b'rt'� F .✓(�J;. .. t gas ..•- .�'J�4. ..r.`'.s y :�•-- _ .s y p .-. r.-..... ..............................•.......•• • w• •e • _. •... I
.r•. .... ,�: ,r r.......................................... ..... .R* •�«�'. Addes ..
Installer Address
UType of BuildiVg,,,- ,^. Size Lot............................Sq. feet
�-, Dwelling No: of Bedrooms..._._..._ ..............Expansion Attic ( ) Garbage.Grinder ( j
04 Other—Type of Building ____________________________ No. of persons.............................. Showers ( ) — Cafeteria ( )
a' Other fixtures _
----------------•---•-----------•---•..-------
Design Flow............................. r .._.gallons per person per day. Total daily flow__-_ ZV
Design
WSeptic Tank—Liquid capacity........._._gallons Length................ Width................ Diameter---------------- Depth..............
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 ( ., ) '
a .per inch Depth of Test Pit.. ......................................
•-- - Date........................................
Test Pit No. 1................minutes
Percolation Test Results Performed b
1 p _____.__... Depth to ground water________________________
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__________.______,___-_-
C� ... '
O Description of Soil ......
U -••---•---•••............•-•-- ---•--•--------w--------------•--••----•-..-----
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 further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed i
. .
Application Approved By
•• ate
Application Disapproved for the following reasons:...-------------------------------- ---------- ----- ----w------------.....---------------------------.....
................................................... -----------•-• ---•••. --•---. •-•-•-. •---•-. �^•� -- ..............................................�
Date
Permit No............................................... ...... Issued„ ... ..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........
Tutifirati of Tomptianre
THI IS TO CERTIFY at the Individual Sewage Disposal System constructed (, or Repaired
by..,„ .. -p, ;. { -----•--------------------•---•-••-----.......
..
t
� f � Instal
-� a �`"
has been installed in accordance with th )roe isions of Article X. ` f Th State Sanitary Code as escrib in the
application for Disposal Works Construction Pennit Flo __________ _ _________ dated .. ._y..e_.
THE ISSUANCE OF THIS CERTIFICATE SHALL°NOT BE CONSTRUED AS A GIIA A1V�EE TI�AT T�iE
SYSTEM WILL F NCTION CTORT. �..
DATE...... ector-- 1
£t �'� Ins 4.
:1 4_-4444 Q<-:;Pl-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No. .. .... FEE. :...........
13i11V0 t WorkstouTtkurtion Permit
Permission-is eby.granted '-- ,.f _.: -..........................................................
to.Cone ( epair ( )in Ind
ividuai �n a e rposal System ! r'
at No_ ' ' .� ,f
.r" Street... �..
as shown on the application for Dispos Vorls CcinstiuCuon ] eytrlt No.. - P4P . ated_.-ts
F �Loard of Health
DATIi _ -•-- warms• - -•---: •:
FORM 1255 HOBBS tip WARREN, IN,C.r,PUSL.ISHERS - - ,