HomeMy WebLinkAbout0024 WEST HYANNISPORT CIRCLE - Health (2) FimuZ..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARDeF HEALTH
... ....�1gv.. v.........OF. ------------------------------
Appliration for Raposal Works Tamitrurtion Prrmit
Application is hereby made for a. Permit to Construct or Repair an Individual Sewage Disposal
system at*
144--
...... ............. . ... .........
..... .... .... ..... K11L.?...............................................
Location- t No,
J------------------------------- .... . .............
;r . .........
Address
..........I, ,.,.&--_----_------------------ ---------------------------------
IV in—staller Address
Type of Build17 Size Lot_-_-/4.0!�_Sq. feet
U
Dwelling No. of Bedrooms...................3..................Expansion Attic Garbage Grinder (
04 Other—Type of Building ---------------------------- No. of persons-__-____________------------ Showers Cafeteria (
Otherfixtures ....................................................................................................................................................
Design Flow ...—gallons per person per day. Total daily flow........... ".._...........gallons.
P4 Septic Tank c,,a,,p,`a_,c,itv/?!!7�llons Length................ Width_--___-_--_---_ Diameter---------------- Depth---.-- .........
Disposal Trench—No_____________________. Width.- T tal Length____.._...... ..__. Total leaching area.. sq. ft.
0
Seepage Pit No.../............... Diameter ........... Depth below o .....&--------
...... Total area.........".f'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------------------------
Test Pit No. 2................minutes per inch D pth of Test Pit......_............. Depth to ground water...----____________-.--.
P4 ........... ..... ...............................................................................................................
0 Description of Soil---------------------- 01.................................................................................................................
x of
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
............................................................................................................................................................................. ------------------------
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_9, o en e undersigned further agrees not to place the system in
�ss
operation until a Certificate of Compliance has - by the board f health.
Si ... .. .. --- - --------- ----- - ------------ ................................
D to
Application Approved By.- .` . ...... .. ... . _ ....................... .. - --- -- - ---------------
Application Disapproved for the following reasons:....................................... ... ....... /..... -------------
...................................................................................................................................... -------D--------------- -a-t-e---------------
------------
I
PermitNo....................................................... Issued.------------------....-----------------.....--------...
Date
---------- ------------ ------------ ---------------------------------
i
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will
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH`
.C�f 4�,
App irttfiun for,Rapood Works Tomitrnrtion Prrutit
Application is hereby made for a"Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Sys at
A
r e 4 ! r
Location-Addres Eta o;Lot No.
i --------- ----------------•-------------• --ep11 1141
. , n
Owner Address
. ......••• - - •- •............................. •-••••-•-•--••---•--•--=--•••••-•-•••----•--•---•--•••..................------.......
Installer Address
Q Type of Buildin ; Size Lot--- "^ _.Sq. feet
Dwelling No. of Bedrooms.................. -------------------Expansion Attic ( ) Garbage Grinder ( - )
`4 Other—Type of Building .... No. of persons____________________________ Shovers — Cafeteria
.< Other fixtures------•----------------------- -
W Design Flow------•...................: ... . .gallons per person per day. Total daily flow........... :__0 ----------------
WSeptic Tank•k Liquid capacity/_F_ gallons Length---------------- Width------------.... Diameter---------------- Depth._.__._______._.
x Disposal Trench—No..................... INidth.........__�, _ Total Length......._....,..._.. Total leaching area_._____;,;_._--_.____-sq. ft.
�. Seepage Pit No.................. Diameter/r__'d--- epth below inlet........jam........ Total leaching area___ *�_i� _'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-__________-__-___-__-_
!Zq Test Pit No. 2................minutes per inch Depth of Test Pit-__-____._-____..__ Depth to ground water........................
P4 -----------------)- -- --..
.......-----•------------------------- ----- ----------------------------------------------------------------------------
W :...:-------------------------------------------------------------------------------------------------------------------
x "-
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 o e The undersigned.further agrees not ao place the system in
operation until a Certificate of Compliance has bodissued by the board of health.
` t
Date
Application Approved B ;�'; .,r° -
PP PP Y ( Date
Application Disapproved for the following reasons:-------------------------- -- - -- - --- ----------------------------------•-----------------------
....-••---.........••--•--•••-•-•-----•--•-------------•••••••-••----------------••-•••--•••••••••-----...--•---•--••-----------••-•----••-•-•--•••••---•--•----•-------------------•------•-----•••--•-
Date
PermitNo------................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. �� x .fl............OF..... ..:"tom raw .. . ............................................
Tprtifira#r of Ton0fitnrr
I IS TO * RTIFY, t the I dividual Sewage Disposal System,constructed � ) or Repaired ( )
by --.-- �l�-� ...........� -----
e In !
staller s
has been installed in accordance with the provons of Article XI of The State Sanitary Code a desc ibed in the
fi-,, * .
application for Disposal Works Construction Permit No------------------_�,�: ._...�._------ dated ........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT,BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM /WILL F NCTIO SATISFACTORY.
p.;
DATE l-6� ......................................7 .- f --•--� ..
Ins ector---•----- •----- �- - ---------"�. .- - -------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAL-+H -
� .
1
,�1�,�+�`� �� Bvr
OF..........:.rT ...h....: "xK. F°�. "ese.._.._:.�..... ...............
No.-IJ.-I--- --- FEE----- .
}�
V r� C�l�n>� 1�tlt print
Permission is hereby granted----
to Constrt cx �� or Repair ( an I dtvtdu l Sewage Disposal Sem r
at No._ �..:'_. y. ---- .e°ox l ''� �' .. dt_ R ._..�... -
--
-" - � Street
as shown on the application for Disposal Works Construction Permit No Dated____ , _ ..........
-.....
Board of ealth
DATE... 7
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
A - -
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