HomeMy WebLinkAbout0041 SUOMI ROAD - Health (2) � 'LA ®ern,
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KEEPING YOU 0RGANIZED
No. 10334
2-153L,
MADE IN USA
GET ORGANIZED AT SMEAR-COM
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........... A�..........O F'............eL%'� ...............................
Appliration for Ropmal lVarklo Tatuitrudion Pumit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.
..._•------%f ...................9. ---. � ! .............................. ------------•-•----_______---------___-_--- ----•-•------------------.-.-.------______
...._
Location-Add res or Lot No.
............................................... .............•••-----••----•••••-----..._.....-•••••----•---•-•-•••-•--•.._....................._.
/ r/yOwner Address
a ZY /1�2i�_.... ................•-•----.....___
M Installer Address
d Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Q, Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ......................................
W Design Flow......................................______gallons per person per day. Total daily flow............................................gallons.
W Septicqcapacity--•--•--•--gallons Length................ Width................ Diameter................ Depth................
Disposal Trench i d oWidth.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..... iameter____________________ Depth below inlet.................... 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_______________________.
r1 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......_.................
P4 ••--------•----------------------•------•-----------•-•••-•------•---••--•---•--•-•-•••.......------.........................................................
0 Description of Soil........................................................................................................................................................................
-------------------------------------------•----•------------------------------------------•---.--..----------------------------------------------•-------------------------------------------•--•_.._.
UNature of Repairs 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 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..... .:.._:....................................................................... ................................
Date
ApplicationApproved By.................................................................................................. ------•----•-•-•---- ...-...............
Date
Application Disapproved for the following reasons_________________________________________________________________________________________________________________
------------------------••-----•-----.............._.._.....------------------...----------•------------••••-••-••-•-•---•-•-••--••---•-------•------------••--•---'..................................
-
Date
PermitNo...1�......--•--•••-•.................................................. Issued......�._;.....�!__ ----- .................
�.L.._._._............. ------ate-------------------------------
---I�To.......�:�. :.... FEE . ...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............r a 4C ........_OF...........�.?�ri!���,��`eh���....................................
Appliration for Uispwial Morks Tomitrartion Vamit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
................1"n...�-.��.... .+�' t�.........--......----- --- -----•----.........----••--•--•---•-•------ ---•-•----------..............---......---
..
f j .Loaa'/" Address s. or Lot No.
"T_ /y
Owner Address
tll� �/.1"r _. ....................................------•--•--........ .....•-•---•----•------
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
PL4Other—Type of Building No. of persons............................ Showers — Cafeteria
a' 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 /4zhe2 Diameter..................:. Depth below inlet.................... 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........................
fi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ----------••••----------•-•-••-••--•-•-•--••--•--••----•....•-•-•...••-----------•..................................•-•-....•-----.................----•-•---
ODescription of Soil.........................................................................................................................................................................
x
V •------------------•-•...---••••--...•••••-•----------•--••-•-•••••--•-•-..........---•........-•-•--•---•-••-•-••._.._..------••---•-••--••--••...-•---••------••••••••----------•--...........•.•.....
W
UNature of Repairs or Alterations—Answer when applicable................................................................................................
Agreemen ......'.... ----�'------�r�?"!--- ---.--�---�'�-/�'l--='----a---- ------- -----------------------------•--.---•-•------•---
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----. ...t..................•----•-•--••----------•-•-•--••-••-•-•----••-••-•••-• ................................
Date
Application Approved BY..............................................................................=-------------------
........................................
Application ------------
Application Disapproved for the following reasons---------------"-"-"----•----------- "--•-------•---------------••------"------------•-•-•-.. a.-•--------------
.............................................................----........................................................_..----•--•----•--------•------•-----•-•-••-•-•-•---•-•-•------•--•••......--•-
{ Date
PermitNo... .................................................. Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF............ . . ''•' � .....................................
T ertif iratr of N11"rrutplitturr �
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by 'Tj,.r�r1.........................•-•-••-----•--...........-•---••---...--------"•-•----••----...--••--•---•-•---._............--••----...................----••---•--.....----
Installer
7 "
.. ---•••-•--•---•-•-•................................•-•---•••--•--•----•--------•••---..........
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................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......... .....T..�'}._.3 Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
r
BOARD OF HEALTH
...........�f a,, O ........Z�.. ..s
r............ F .................... ...............................
No..... .f....... FEE........................
Dispasal ork_ s ��Tomitrurtion unfit
Permission is hereby granted...... ;.... �' `�/'e)�� ' 'f 4
--..•-----------------------------------.......
........
-.----------
.---------
to Construct ( ) or Repair ( an Individual Sewage Disposal System
atNo..........."L'.Z... .... .k'.-----•--•................•-----.._.... ----....--------•-••----.....---•---•-----------------------•-------•-••-•--------..
" street
as shown on the application for Disposal Works Construction Permit No.... Dated___ :_.�"__%:. ....................
Board of Healthy
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS