HomeMy WebLinkAbout0071 SOUTH STREET - Health (2) 0
No....9!�-4---•----•- 2�0_ 130 F�tt ..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
&e� Gvr�-•_0F......./�..��z .%S't... 6 Z
� 1 91,
Appfiratian for J%iposal Workii Towitrurtion Permit
Spplication is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal
ystem at: �� �r h/�S- (�/�'✓ yly�(
---...1�o_� s.- �� =.......SI C-_�Z/.X..I,.-
vLocation:Address ............................................ Lot No.
Owner ,dle
AAd sss
............. hlwa s.------------------- --------------------------------------------- ds- ....................................
Installer
dType of Building Size Lot............................Sq. feet
U Dwelling—No. of B drevms................................. _Expansion Attic ( ) Garbage Grinder ( )
p-, Other—Type of Building -.- No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ......................................................
W Design Flow............................ . �..__.__--gallons per person per day. Total daily flow............................................gallons.
9 Sejt�.;aan k— 'd capa . ® ...gallons Length................ Width---------------- Diameter---------------- Depth-------------
y, ��
l c�sal "1^refre�i—No.........I......... Width.................... Total Length.................... Total leaching area_./t.X0_,0„__sq. ft.
3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area--__..__-_-_-_____sq. ft.
Z Other Distribution box (-7() Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date----------------------------------------
aTest Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water--.-_-.--_._-__-.-__----
�14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water.___________-______-_--.
---•------------------------------------------
--•------------------------------------------------------
O Description of Soil......... ...............`� ..--•---- ,C1_
x �U
V -••-•••--•--------------•••-------------------------•-------•----------------------•---------------•----------•---•-----------•----.....--•----••---•-•---•--•----••••••••------------------------------
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 iss/edbye oar of ealt .
7�
Signed ..._.. ••-----•••---_..l"' -....---•------•---_.....
Application Approved BY------�-- -- ----------------•--...-•-- ------------------------------ ............••... Date---
- ----------
Date
Application Disapproved for the following reasons:----------------------------------------------------------------------------------------------------------------
------------------•-•---------•----------•---------------•••------••-•-.................--•-
Date I
Permit No.--------_�'6--- Issued.
Date
f
!'----------• Fix _.: ..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............ /c ........OF....... :....•-.........................
Appliratinn for Rfipoiittl Worko Tonitrnrtion' ramit
Application.is hereby made for a Permit to Construct,� ) or Repair ( ) an Individual Sewage Disposal
System at.: � • - '. � ; +Fr` f r
I !t1t`# /'_ =��/A�� . P� ... � ... f.11r r lG ,S i r 1...... r/d_- .
.. ..... _ ._ _ ..._ _r
Location Address or Lot No.
tr'&
� Owner Address
p
............ ...................s:.-s-- .................
Installer Address
UType of Building Jf /a/ Size Lot............................Sq. feet
,-, Dwelling—No. of )ems............................................Expansion Attic ( ) Garbage Grinder ( )
Other 'T e of Building t' j _ No. of persons____________________________ Showers — Cafeteria
a YP g 1 ( ) ( )
a Other fixtures ____________________________
W Design Flow ___-_gallons per person per day. Total daily flow--------------------------------------------gallons.
�W �c Tank I„iquid capac`W,,b,..r� _gallons Length................ Width---------------- Diameter..._........... Depth_-__________. .
x 6se , .f;t+l+
[1ecnal �f-> Ieh=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 water-__________________-._--
�14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
P4 •--------------------------------�----------------------------------------------------------••--------------------------------------------------------------
O Description of Soil....---- '=---------------" " ' rg _
x -----------•-----------------•------• ----------------------------------------------
V ----------------------------------------------------------------------------------------•-•--•---------•----•--------------------------------------------------------•---
W
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 XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss/edbbyhe oard of kealthSigned -------•-•-- ./ k
Date
Application Approved By.........ei€........................................
Date
Application Disapproved for the following reasons------------------------------------------------------------------------------------------------------------•----
•----•-------------------------------------------------------------------•-----------•-----------------..................................................................... ----------------_-_--
Date
Permit No..........r /w----.---------------------•--_._... Issued. •---------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........0F.... . .... �.� ?. ; �„`a : f Ly'` ...........................
(Intif iratr of Tnntplianr '
THIS IS TO CERTIFY, That,the Individual 'Sewage Disposal System constructed ) or Repaired ( )
r to > t'r)fJ x y > �, e:._,
by = a�
f y9 Installers{y yam'
at-------------- -,`-----`---- .`.-'.�--------.''r'..f .,��",.� ..... t'......--•----•------,f'IP f'f#'�/,�dG l "' �--�-�-----'----•------------•-------------•- I
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No------ dated--__. A_•. ?__.„._ ......__.......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT,THE
SYSTEM WILL UNCTIO SATISFACTORY.
s--4e17 r- �.
DATE----;; Inspector __ _ '� ` 'Ive
rl
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.-,e .............pr°r ?. ...... OF........� Yr - �` ...............-------........
No._•-•-. .----- FEE =-----•---
Permission is hereby granted.........,f�-ps`•: ! � t�-
- = ----------------------------------------------------------------------
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
atNo. y r ----------------------------------------------------------------------------------------------------------------------
} Street
as shown on the application for Disposal Works Const ction Permit No----- • ^-______ Dated______
_ ----------------------------- -------- --.---------- -----------------------
Board of Healt
o
DATE---------•-----9-�----�'�-------f--- ---- ................................... �::...�,, "•'�' r � �:
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS '