HomeMy WebLinkAbout0037 TANAGER ROAD - Health (2) 31 Taro�w IMP , IrlI6,3
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THE COMMONWEALTH OF MASSACHUSETTS
BOA R® H EA T
... ..OF........ ...
Appliration for Bhipasat Marks Tour rurtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Sy t e
`, ... ... .......... �.. -----.----- ---
cation�dress or Lo o.
. . ................................. /. ., . .... ........_... . . . ..... .
wner Address
a ..... .............................•-
Installer Address
U Type of Buildi � Size Lot...........................Sq. feet
Dwelling o. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
44 Other—T e of Building No. of persons............................ Showers — Cafeteria
Other fixtures ......
W Design Flow....................... allons per person per day. Total daily flow._............._._:..__..._..__.._gallons.
WSeptic Tank Liquid capacity._ .: .. allons Length................ Width................ Diameter................ Depth................
Disposal Trench—No..................... Width....................Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No._+r............... 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....y_-_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........................
O Description of Soil....... - --"............................................................................ -----------------------------------...
x
U
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 issued by the board of health.
Sigd-•-• ................:........................••••-•-•-••-•--•-•--...-------• ................................
ate
Application Approved:By------ �-- ------•
.11 Date
Application Disapproved for the following reasons-.....................................--.........................................................................
.........-•------•-----------------------------------------••---•----•-----------........--•---•----.--••-
Date
Permit No.........................: Issued Date---•---•-----•-•--.....--••-•-•
...... f..... Fimic............................
THE COMMONWEALTH OF MASSACHUSETTS
-
-' BOARD O-F HEA1 TV_
......./A� ............OF......... ..............................................
ApVfirafivu for %Vasal i8orkii Towitrurtivit Vrrutit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
y at;.,
.............. . j
...
..V L.4a.i.o.n.1-,.Add re.s.s....... ......................
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7................ .o.r...L..o.t T* ............ ...... ........
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........................................... ..................................................................................................
tjOwner Address
............................. ..............................................................I................................
Ga
Installer Address
U
Type of Buildm Size Lot............................Sq. feet
.�3
Dwelling o. of Bedrooms............................................Ex pansion Attic Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers ) — Cafeteria ( )
Other fixtures :........................................................ . . ..........................
;ff-=1-----------------*------------------ o�
Design Flow.,.....................'?...t;.,j.,.,,.,gallons per person per day. Total daily flow............................................gallons.
9 Septic Tank-L-Liquid capacity/ _.4jallons 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.
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__________-___-_.__--_--
�-4
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.__...______--_-..__-._.
P4 1z
.........................................................................................................................................
0 Description of Soil..........-1
x - .--.:......................................................................................................................................
.......... ..............................................................................................................................................................................................
U
W
........................................................................................................................................................................................................
�r.
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 issued by the board of health.
Signed....................................................................... ....../..................
Application Approved By........... ............... �./.......
.. ...... .... .........................
Date
Application Disapproved for the following reasons:................................................................................................................
.........................................................................................................................................................................................................
Date
PermitNo....._................................................. Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 1 OF F, HEALTH-.,-;.4 4—
fi
...... .. ...............OF........... ............................
Tpriffirate of Tout;dianre
TjfIS IS TO CERT!TI That the Individual Sewage Disposal System constructed ( 41'or Repaired
by.... .. ....... .....................
.................... ..................... .........1 .......................
.....
.......... ....... _7
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rinr
at...... ............. - ----
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has been installed in accordance with the provisions of Article XI of The State Sanitary Code- s I e4 in the
. ..................................
application for Disposal Works Construction Permit No............................f�------- dated-------- .., Z_
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNC ON SATISFACTORY.
DATE....
.71 ............................................ Inspector ... ....;7..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF,-HEALTH-,--
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7 No..... .
............. ....OF...................1-1..................................................................
......../....... ...............
Ropus I Wprks tustrudivit Prrutit
reby granted........ ................................................................ ............Permission i�
posal in pte2V
to Constru �Fyqj��r -an Indivi u ewa 7 D
A
at ....../
-��/............................. ......... ................... ................ ......
/..............
St t
r
as shown on the application for Disposal Works Construction Na._ ated-_D -.-/............................
-- -- - -----
------------- ------------ ,---d o Health
,----ca -Boar f ..........DATE.. ----- ....................................
/17 -------
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS