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HomeMy WebLinkAbout0061 GRISTMILL PATH - Health G 14 jv 0-h,5 l 0 f) S M r L L. 5' - �No.._/I--=--------• Li!/ u��i' F��.... THE COMMONWEALTH OF MASSACHUSETTS- B®ARD OF HEALTH (� c"h- - ---------OF....e "LdI tdv[.. Apptiration -for Uhiposal Workii Tonstrurtion Vrrnfit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal SYSUM at• ............................... .A..............�----'--- ----------------- ------ ----------------.------------ cation-Address r L o ' $'------•--------•--•. ............... ....... 1.� ! �.�� ............................. Own- ress ` t.. ddress Q Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms _..____ ........................... Expansion Attic-(kZ) Garbage Grinder h6 aOther—Type of Building uL_---------- No. of persons......S................. Showers Cafeteria (kb Q' Other fixtures ------------------------------- -- W Design Flow.........S-U---------------------------gallons per person per day. Total daily flow........... . -------------------- WSeptic Tank—Liquid capacity/�U�__gallons Length---------------- Width-------- Diameter----_.......... Depth.--.------------ x Disposal Trench—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 ( Ji) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date---------------------------------------- Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water-.------.--.---._-.----. f� Test Pit No. 2________________minutes per inch Depth of Test Pit.................... Depth to ground water__.----.___.__-.__-_--_ -------------------- ---------------------•---------••-•------------------------•-----------------......................................................... O Description of Soil----------6---------a2---�---'------ ............................. --------- -- x .... �`'T 'GoGr.�sE s -__o� �-.._ 3.-T ---- -c.. -;----� �1 �t arvsr bc® /J-.0 1-eet r" W ----------------------------- -----------------------------------------------------------------------------------f.� ----------—----------------------------------------------- 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 su d by e boar of he th. Signed fi +r� f d:` .... g { Date Application Approved By-------leffollowing ,/-L ' Datee f Application Disapproved for t reasons---------------•--...........------------•---•-....--•--------•-----------.._.__.......-------•------------•-•--• ...................................:..................................................................................................................................................................... Date Permit No........Z�/--_---------------------_---•--•---- Issued..... - ----------- Date -7 G THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEA TH _ .. ----OF..... �..._y. ,or Application is hereb made for a P r 't to Con ruct �or Repair ( ) an Individual Sewage Disposal System at: X ' .... .. - ocati Addr s of 2491 7 1- �Y.:�----- 1.7��d�c. y /1d :.............................................. W caner' Address ... . .. ....... ......... ........................ ............................................................. nst Address UType of Build' '� Size Lot............................Sq. feet Dwelling No. of Bedrooms......................-..-._....._......._.Expansion Attic ( ) Garbage Grinder ( ) a .: y Other—Type of Building ........... No.""o� persons............................. Showers — Gi YP g -----•--•---•- .f p ( ) Cafeteria ( ) Otherfixtur s ------------ ----- --- ----------------------------------------------- Design Flow------------ - � �.�---.�--....-•---------------_. W -....._ ._.... Mons per person per day. Total daily flow............................................gallons. WSeptic 'I Liquid capacitv�Z�.gallons Length................ Width................ Diameter................ Depth.........------- x Disposal Trench—No. ./----- ...--------- Width-------------------- Total Length.................... ,Total leaching area..:_...._....._....sq. ft. Seepage Pit No............ iameter.................... Depth below-,inlet..................•. Total leaching area.... -..........sq. it. z Other Distribution box ( + '' Dosing tank ( ' ) — 6 :;I_ _ Percolation Test Results Performed by.-_.._..._.__--- -J .-.z!r�=._. .�. Date------------------------------------_.. a •. Test Pit No. I................minutes per inch., Depth of "Pest Pit.................... Depth to ground water........................ (s, Test Pit No. 2.---------------minutes per inch Depth of Test Pit.................... Depth to ground water.............----------- - ----------------------- /= �/ - --- Description of Soil. r - -- � .�. �. �.s�' / ------ l---------•--------------- Vlj D ='--,---------------•-------------••------------------••---•--------------•----•------ - ----------------------- -----------------------••--•--•-------------.....--••-•------------•--•-•----------------•------ ---------..-----------------•----•-•--••---------------•-----•-------------- r VNature 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 \I of the State Sanitary Code— The undersigned further..agrees not to place the system in operation until a Certificate of Compliance has been issued bv the board :� health. Signed............ / -----G \----- ---- -------------------------- Date f Application D'isppproved roved BY =-- -- ------ ----------------------------------------------------------=------- ------------------..Da e--- Date Application for the following reasons:................................................................. •--•-•--------------......................... ...............................`_------------------------------------------------------------------------------------------------------------------------------------- Date Permit No.----------1 L ------------------------------------ Issued.--- •---- 1 Date s THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............. ............................OF...........`%: ...��.. Qrrtifiratr of f21aamplia4ta T S TO CERTIFY�iat Individual Sewage spo ^lY S s m con structe ( or Repaired ( ) bY--.....---- ---------------------•••......••••- Instal at.--�---- - l.Ci C----- ` _ has been installed in I ordance with the provisions of Ar 1 I f e State Sanitary Code as described in the application for Disposal Works Construction Permit No...... ...... dated.. . A— s ._+-. ....._.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE© AS A GUARANTEE THAT THE ;4 SYSTEM WILL FUNCTION SATISFACTORY. DATE------------------------------------------------------......................... Inspector............................................................................... •. a; t. THE COMMONWEALTH OF MASSACHUSETTS { BOARD F .,J EALTH / ......../......... FEE. N� "I. ....... r � rr aa r iaag� �' d4,' Permissi n ,s _ eby granted:-- '-- _ ---- ------- (G�.:/. ... ............................. .. to Construe or Ij�e ai,' an In-i _(� !f p ' ) y ual Se e Disp .Z ystem at No.----- ---- -���==��c to ��! 1� ----- ---- ---------------- as shown on the application for Disposal Works Con ruction Perm' No. ... .............. ated.:.._l ._........_:..... ...:.......... ----------------- -------- -- ---------- --- .... �� -_ ' --- C ----••----•-•-•--••-•••-- �;'� �-• oard of Health DATE 1 -- ...--- - FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS