HomeMy WebLinkAbout0087 WINTER STREET - Health (2) Fql VN1Y1T2('
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......OF....../5 ..............................
Appliration for Raposal Workii Tangtrurtion Vrrmit
Application is hereby made for a Permit to Construct ()�) or Repair an Individual Sewage Disposal
,System at:
.................;t9. -
<' '0!L re../. ..... ....&.................................. ---------------------- .............................................
Location-Address or Lot No
109
47- -,7----------------------------------------- --------
.................................... ............. . .. . ... ..............................................................
Installer Address
U
Tle of Building Size Lot----- ----------------_---Sq. feet
Dwelling—No. of Bedu�oms----------!/------------------------Expansion Attic Garbage Grinder
Other—Type of Building ... --- No. of persons____________________________ Showers Cafeteria
Otherfixtures -----------------------------------------------------------------------------------------------------------------------------------------------------
Design Flow___._......................... . _gallopsper person per day. Total daily flow............................................gallons.
9 Septic Tank—Liquid capaci 7d�p
Length................ Width.__________.._.. Diameter-_______________ Depth____________...
x Disposal Trench—No......_._.. Vb'i h.................... Total Length.................... Total leaching area--------------------sq. f t.
Seepage Pit No.h)A0._i__-_ I tam er.................... Depth below inlet....____............ Total leaching area------------------sq. f t.
Other Distribution box C ) 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 Depth of Test Pit._................_. Depth to ground water-___-_-_____-___-___----
--•------------------- ---------
0 Description of Soil------------------------------ ' ............................................................................................----------------------------
--------------------------------------------------------------------------------------------------------------------------
x
U ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
.......................................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------
....................................................................................... --------------------------................................................................................
Agreement: .
The undersigned agrees to install the afore scr bed Individual ewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary e The undersi i ed further agrees not to place the system in
Sanitary
.1a
operation until a Certificate of Compliance has bee s ecl by the boar .),f health.
Signed......A ........igne .. .............
Rb Date
s e
Application Approved By............................. .........
.................... ............. .................. ----------------------------------------
Date
Application Disapproved for the following reasons:.............. .................... ..........................................................................
.......................................................................................................................................................................................................
Permit No..-tit -"I� Issued. "/;�—3 Date
................................ 7/...... ...................................
Date
--------------------------------------------------------------------------------------------------------- -------------------
No.....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Applir ation for 43hiposFal Works Tiamitrurtion "eraaatt
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at:
A
Location Address f or Lot No.
f / b pi^/ /tv, a ...._ f...................................................�?, a., / .........................
W r owrt J px ddress
lk ;t
- :�'41_- :----•----____----•_________________
............ .p_.. - __ ..-....._______________._____.___._._______.__ _.._..__-
PQ , �
y Installer Address
Q Type of Building Size Lot----------------------------Sq. feet
U Dwelling—No. of Bedzgoms____________�___________________________Expansion Attic ( ) Garbage Grinder ( )
Other—Type e of Building '��p� yp g ___,::_'.f�_____________ No. of persons............................ Showers ( ) — Cafeteria ( )
04 Other fixtures ......................................................
Design Flow................................._----------gallonsj)er person per day. Total daily" flow.........................._-----------------gallons.
WSeptic Tank—Liquid capacity------------gall no s� Length................ Width________-.-__-- Diameter---------------- Depth__-__________---
x Disposal Trench—No.___________________ Wi h_______________-____ Total Length.................... Total leaching area_._.................sq. ft
Seepage Pit No.✓�00.._, . Main ter ______________ Depth below inlet.................... Total leaching are;.t------------------sq. ft.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date..............----------------------------
,� Test Pit No. 1_______________minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
(Z4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
P4 •------------------------------=
ODescription of Soil----------------------------- �w" --=--•--•-••----•---•--------•-------------------------------------------------------------------------------------------
"�
W
UNature of Repairs or Alterations—Answer when applicable._------------------------------------------------------------------------------- --------------
----------------------------------------------------------------------------------•----- ` -----------------------------------------------------__------------------------------------ -----
Agreement: f� - .
The undersigned agrees to install the aforedescribed Individua�5ewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary t ode— The unders ted further agrees not to place the system in-
operation until a Certificate of Compliance has beeissue by the boar 3;of health.
Signed--,A--- .......
-- 5
Date
ApplicationApproved By--------- ..................................................../ "",4 a ------------------------------- ----------------------------------------
Date
Application Disapproved for the following reasons---------------- ---------------------------------------------------------------------- --------------
r
Date
PermitNo:__. •�'..L/_---•-•-•--•--------------------- Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF............ ..........................................
rtifiratp uaf ��aaatr�t�a�arP
HI �ISJO CE_TIFY Th?t the Individual Sewage Disposal System constructed OO or Repaired ( _)
by.,_ rl -
Installer
57
at.---------� -_----pall j�-�`---=----- ---- ......-........! " '��./_�..................................................................................
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 CONSTRU ® AS A GUARANTEE THAT THE
SYSTEM WILL F NCTIO SATISFACTORY. _
DATE......... --------------•--•--••----•--- Inspector---•-•. -- -- ------- •--•-•-------------- -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. 4"-, 7/7
.............. �.....................OF.......A...7.' .:..........-.-..--------------------.-........_......_..-.-.....-.
No:- FEE---< -............. -
�is�rBs� ���� . Haas aart��at exaatit
Permission is hereby granted____ _.. :___.
,� - ------------------- ---------------------------------=- -----••---•-----
to Construct ( ) or Repair ( ) ark Individual ewage Disposal System
at No.-=---- --------�_",!_ _1' `Y---.................. fY'err.6c-f'7------------------------_-_ ----
Street
as shown on the application for Disposal Works Construction Per It N •{- �~ _ Dated____
� r _
,P -
.- ' i
kA
Board of Health
DATE.- •-= ----�- ..
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS