HomeMy WebLinkAbout0056 SMITH STREET - Health (3) C� Sri��-t-�n
�� ������3-ex�j
�;
No.. ���.. 2--O O "
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEA T
C,117iL.........OF....... .. .......... .. ... - . -- .................
Appliration -fur 43iiipwia1 Varkg Tatuitrurtilin Vrruiit
Application is hereby made for Per to onstruct ( or Repair (" ) an Individual Sewage Disposal
System at: � �--
J
Locatio r s Lot No.
w Address
staller Address
Type of Buildir. Size Lot............................Sq. feet
U Dwelling— o. of Bedrooms------------------------------ -- -Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures ....._..
d ---------•-------------------------•---------------------------------------------------
W Design Flow__ ____________________�.__.____ _._ gallons per person per day. Total daily flow______________.-___- llons.
--
W Septic Tank
Disposal capacity/ ._..__.gallons Length---------------- Width................ lliameter___._..._..____ Depth................
x Disposal Trench—No. ____________________ Wid h___.___._r___ ____ al Leth,�_______ Total leaching area-.--._--_---_-__--sq. ft.
Seepage Pit No.-------� Diameter. l.�'_I---- e�y6 in a Total leaching area. sq. ft.
z Other Distribution box ( ) Dosing tank ( )
~' Percolation Test Results Performed by-•........................................................................ Date----•----------------------------------
aTest Pit No. 1................minutes per inch Depth of Test Pit..................... Depth to ground water..-----.--_------.--_...
Test Pit No. 2................minutes per inch Dept f Test Pit.-. .....1...... Depth to ground water._.......__.__.._______.
-•------------------------------ -•-•---•••--•• ....................................................................................
0 Description of Soil........................................... = --- .......................................................... ---------- ----------------
x
M ..................................................................................................................... .. ........... . .............t...... -----------------
U Nature of 'rs or Alterations—Answer when applicable.-- -- ------ I- ------------------ - -/-----!------ ----- --------
------------------------------------------- ------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss ed by the board of health.
�r
Signed ---------- ---- ;
Application Approved By....... . •. -----••-. .•-• ---- �� . ------••••-- t
-tate
------------
Application Disapproved for the following reasons:-------------------------_____ -.-..-__----.__-__-.-_____-_-_---------_-_-_-_-..-.-__-----.---••---
--•-••-•--•-•-•-•-••-•------•--------------••--.......-----------•--•--------•---•-
Date
PermitNo........................................................ Issued...................... -•------........................
Date
No........
.. Zti F>�s.... ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® HEA T
"jrj . O F...... ...:....::. . .. .:. ...........................
Appliration -for Disposal Works Toustrurtioo Prrotit
Application is hereby made'for a Perm to Construct ( or Repair an Individual Sewage Disposal
System at
Loqati s r Lot No.
.__ ..... .. ................................ ......................
O r ,rA dr ss
Ww ' �.... ..........' - _• -_ --_•_--_ - -•--•-• -----• -•--•---
staller Address
d Type of Build i Size Lot............................Sq. feet
U _ Dwelling roofBedrooms,----------:---------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—'Type of Building ........................... No. of persons_---____-_-::__-__- ...... Showers ( ) — Cafeteria ( )
a
d Other fixtures'
-------- --- -- ----
w
W Design Flow_ __-__•_--•____________ _____ allons per person per day. Total daily flo _._.:____........._._..:_ .-..gallons.
Septic Tank Liquid capacit _— --gallons Length................ Width_........ Diameter---------------- Depth----------------
xDisposal Trench-No ____________________ Wt thy..,_....,.)__ __. 1 Total leaching area..........._--------sq. ft.
Seepage Pit-No.... ..--.f ' Di' meter�(l:v l�_- ep el in e ...._ ..:__r Total leaching area_______ __________sq. ft.
z Other Distribution.box ( ) Dosing tank ( )
~" Percolation Test Results Performed by-------------------------------------------------------------------------- Date---------.----------_-
a Test Pit No. 1-_:_ Depth of "Pest Pit----- _________ p g_____ Depth to round_water.. ---------------------
Test
Pit No. 2................minutes per inch Dep of :Test Pit.. _........._..._. Depth to ground water--,__.-.-__-__--__-_-._.
P ------------------------------- ------ . . -----•-
0 Description of Soil---------------- " = - -- --
U -------•---------------------------------------•-••••.........••-•--------••-•-•-••-----•-••--•-------...---•••••••-•-----•-----•---=------------------------...... . .........I--------------------
W •------------ ------------------ -- ---------------------------------------------------------------------------- ---------
Nature
U o rs or Alterations —Answer when applicable__ ►. .. ------- __._
�'�
------------- -----------=•------- -------------------------------------------------
------------------- - .......--- - ------- -------------------
Ag eement
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 s led by the board of health,
f4
Signed - _S. _e_.. f "!"��'*"" �...._.. •-------
Application Approved By.::... ... = - ' -- ---------- - - �^� -- -� �-�-�a--------- ,
Date
Application Disapproved for the following reasons:---•-- •--- ------ --------------------------- ----•----•-•---------------------------------•----
Date
PermitNo............................................................ Issued...................... .................................
Date
THE COMMONWEALTH :OF MASSACHUSETTS
BOARDd9i5
, HEALTH
i1
K
:............OF. . ...::.... ...::. .. :. . .... ....� :: ..:.... ..............----
Trrtifirate of Toutliliatirr
LkW IS TO CERTIF hat the In vdual Sewage Disposal System constructed (' ) or Repaired ( )
by----- f ". ........ --••#41,
... -••-•--•-•-------••... ...........................................................
at --- X--•` ---•-------•------••------•----•------••---------------
has been install e in accordance with the provisions pI of e State Sanitary fojeA des ribe�n the
application for Disposal Works Construction Permit No..:........................ ...... dated._- /ARANTEE
,........
7
"THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A G THAT THE
SYSTEM W1 U CTI,ON ATISFACTORY.
DATE-- - ------�� �................................ Inspector--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD-
OFHEALTH
1 ,
`<. OF...... L .....
....................................
No. � e. FEE._ ..............
Ding arks - o urtion rmit '
Permission-is hereby grante ,•; ,_---- _;tio�
:_..: .................•------••-•--•---•---•-----
to Construct f� ) or epair an In 1 a ew isposal Sy em
--
pP pat No-41.4 Street
as shown on the application for Disposal Works Constr`u ermrt N Dated._ __. ______._.
Board of Health ._..........�
a7
DATE..: ?
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS