HomeMy WebLinkAbout0070 SHADY LANE - Health (2) i
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No..*J41..... Fw3................
...
THE COMMONWEALTH OF MASSACHUSETTS
ROAD® OF HEALTH
(nJ:JU .............OF.......d� it �(,1-� Q.
Appliration for Dtsp a a1 Works Tomitrnrtiun ranfit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
Systemat: , ... ... ...... .............. .. .-•-• ---.............................. ..... ......
Location- ress V[`y y or Iyot No.t -A&WI � +4 �
•�r- - n Owner/n'�- 1 � / Ad�drge�ss� )L �q,�
W,•� •----�1/CiGS_..... !`:bd _r._t. !-NS.........�:........ ._.��..:.. ....� ......._. ..+v..d..°-'............. iYrl� a
Installer Address '
Type of Building :" Size Lot............................Sq. feet
Dwelling No.:of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures .........................------ . ..
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............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 ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_-___---_____-__---__---
G%, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ....................•...................................................................................._...--•------....--------•---.........._.......-----
0 Description of Soil........................................................................................................................................................................
x
U ----------•-. -•----•--•--•-----••••--....---•--•------•-----------------------------•........••-•--....••----•----•-------•--•-----•------•-•-•--......•.............................................
W
U Nature of Repairs or Alterations—Answer when applicable-- �d--.. ` _S_.._ 'U.Z-.
za1/1......I...� ...sue- .mom....................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of i 5 of the State Sanitary Code- The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beguAfued by the board of health.
Signed. -- , ............................. -- `5.... 1.
Date
Application Approved BY......
i� .�-
ate
Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------•-------..........
------•-------------•'------------•-•--•--•-•-----...-••-•--•--------_---'-•-'•-------•'.....•-----....---------------------------•--•--------•----------------------•-------•-•-------•--•------......_
Date
PermitNo......... �� '. 1/.......................... Issued---------------------------'------"-"•"-""-'-''--'
�� Date
No..*J ff..... F�a...'��......Q.
THE COMMONWEALTH OF MASSACHUSETTS
• BOARD OF HEALTH
r-D—W1k.-I................OF......`��5. .nt�uS 6 -.•----.._..•---------=-------
Applirtation for Disposal Works Tonstrnrtion Pumit
Application is hereby made for a Permit to Construct ( ) or Repair ( /an Individual Sewage Disposal
System at
............:... ... ........ .... ,u....._......... �1 Ni E. ................ ------_.�..._...•-•••---•-••-----._..........•---_•••-•---••--...--------------•----..........•--
y,location r ss .a..0 + or Iyt No.
.hY_.!_..�.... .. •Gt/4 �.7....�-�. I _5 :. rG:!V---' =
Owner/ �^-� Idr�s�
Installer Address
QType of Building Size Lot............................Sq. feet
Dwelling—No. of'Bedrooms.__..... ____________________________Expansion Attic ( ) Garbage Grinder ( )
Other—Type e of Building No. of ersons____________________________ Showers — Cafeteria
12.1
YP g P ( ) ( )
Q' Other fixtures ................................. .
W Design Flow............................................gallons per person per day. Total daily flow............................_...............gallons.
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 ( )
'-� Percolation Test Results Performed bY----------- .....................................................----_... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit--------------,..... Depth to ground w ter........................
Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to`grou water........................
a r
D Description of Soil .................................................
V ............................................................................................ ...............................................==........................................................
W ---------•-----------------------•--•-•------------•--•----------------------•--------•-----------------•----- ----- ---------- --------------------------==---------------------------------------
UNature of Repairs or Alterations—Answer when applicable_. = 4ts . S_._. E i.��Q -.
—► _l 1 1 Q,-o-- A S.4a.v.---SY ' j 1.. ........... ....... . Z'a_y ....................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b ued by the board of health.
Signed � � ''-------------------- ----/... �5 �f
Date
Application Approved By............. ....................................... ...-----
ate
Application Disapproved for the following reasons:................................... ----------------------------------------------------------------------•-----
••••.....•-••...............••-••••••.._....r....__-------__________--•-------------__..........................................--_..._--------------------•------------_---------------.__.___________
Date
PermitNo..-----.. .......................... Issued.......................................................
Date
.r
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.....W..................OF....: / !Vy1Y .........._..........-._....--........
'T.rrtifiraft of TompliFanrr
THIS IS TO CERTIFY, That the ndividual Sewa Disposal System constructed ( ) or Repaired fIll
by •/,,5_..__. ..e�? - a✓-j-/__ _-------------------------------------------------------------------------------------•---
S�1/ / ,/�/ �q Installer-
at................T... �6G x L-.:......v!-..,. ..P_!_ !>(✓f.s ----------------------------•------------------------------------------
has been installed in accordance with the pr isions of T-!"Y, 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No...... ________ dated-...............................................
THE ISSUANCE OF THIS CERTIFICATE WALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-•-•••-••................7_.'�.:' .`Z._:..- .-__...._•---. Inspector_:. = - = s ..........................................
THE COMMONWEALTH OF MASSACHUSETTS ,
a
BOARD OF HEALTH
No... /..'.. !/.._. ..........................................OF.......14JC7l�ofl._-o,4/�!: ....................... FEE................`. .
]Disposal WAs 05onstrurtion rrmit
Permission is hereby granted c � r� '� _ _. o�,r :.._�.�...................................................
to Construct .( ) or Repair an Individua ewage Dispos,.4 System
at No........Ste'`-_ = ✓_. .�.__... _.. ; ,!�/A//-. .._.. 1 -
Street r
w. as shown on the application for Disposal Works Construction Permit No..{, / -_ Dated..........................................
______________________________ t� ......................................................
Board of Health
DATE...............
.................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS