HomeMy WebLinkAbout0012 HIGH VIEW CIRCLE - Health 4-1
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THE COMMONWEALTH OF MASSACHUSETTS
_BOARD OJE5 HEALTH
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® � Appliration -for Dhipoii tl Workii Tongtrurtion Pprutit
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Application is herebDv made fo a Perm* to Construct (//) or Repair ( ) an Individual Sewage Disposal
# S st at:
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�• L ss or Lot No.�A
��••�� Owne"'� ddress
...................•••-------• ---�--�`.....=-`-�--•------`•-•---- --••-•--•-- --------- ---------------------------••............................................._
Installer Address
Q Type of Building Size Lot.... G...Sq. feet
U Dwelling—No. of Bedrooms-----
---------------------------------------Expansion Attic ( ) Garbage Grinder
per, Other—Type of Building ____________________________ No. of persons._____-___-____-_______--___ Showers ( ) Cafeteria ( )
p'' Other fixtures ----- -----•----------------- --
W Desi n Flow_____________________;_ A� gallons per person per day. Total daily flow__- _.._..
g g< P P P Y Y gallons.
WSeptic Tank--Liquid capacity gallons Length................ Width........... Diameter______..._•.._--. Depth....---.-_.--.-.
x Disposal Trench—No. .................... Width..............._ _ t i Total leaching area------------:-------sq. ft.
Seepage Pit No.. . -•--_. Diameter._,(-- - W ide Total leaching area -------_-sc it.
� -- �•-••- /-`�``---- P � -- g � 1•
z Other Distribution box ( ) Dosing tank ( ) a � s �''' AAe`��T
Percolation Test Results_._. Performed bY.......................................................................... Date------•-----------------------------....
a
Test Pit t ------------minutes per inch Depth of Test Pit.................... Depth to ground water....• ..__..---
(_, Test ,P-itNo. 2................minutes per inch Depth of Test Pit.--_____--_-._.__..- Depth to ground water---------------..-..____
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Description of Soil y V�4 - `"' /a'
V 4. �
-- .......................... - -- ------ -------------
--- ----------
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 NI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has n issued b e a of heal
Signed - -------•------------------------ t 7 1
Date
Application Approved By--------. -----------•---------------•-- ` �.• ��
• � Dat
Application Disapproved for the following reasons------------------------•-•------•-------------------------------------------------.-----------•----------------.
---.--•--•--•----------•-•-•----------•---------------------••-------------------•---•----•---------•------------------•-----------------------------------------------------•------•-------------------
�y � Date
PermitNo...... ......................•----------------------- Issued......................I---....--
Date
No.. / Fiz$..........A9
THE COMMONWEALTH OF MASSACHUSETTS
OA R D OF HEALTH
,ppfir4on -for Utapoiitti ork� Tonithirtion Vrrmft.
" Application is hereby made for a Per to Construct (M) or Repair ( E) an Individual Sewage Disposal
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,. ss ,s '//, or mot No. �(/',(/
Owner ....... --•----------------------- ---�.... ddr... J
Installer Address
Q x 'Type of Building Size Lot_:_���•_..Sq. feet
�Y� HDwelling—No. f,Bedrooms____________________________________________Expansion Attic ( ) Garbage Grinder (401'
aOther—Type of Building ___________________________ No. of persons............................ Showers ( ") — Cafeteria ( )
Q Other fixture --- - -----------•----------------------------------�-•--------- ---------- -•- --------••._.----
•
W Design Flow........".____._.._. �_____��____)gallons per person per day. Total daily flow______ O' ......................F_..gallons.
„S ptic "Tank Liquid capacity !/ _gallons Length________________ Width..____....... ._ Diameter---------------- Depth.----.____.._..
04 x Disposal Trench—No_ ___________________ Widt L__ t Total leaching area-.--.----.____...sq. ft.
--Seepage Pit No-______/ Diameter__._ Total leachiu
I - �/:o''� `�Lw - lef g area sq. tt.
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z Other Distribution box ( ) Dosing tank ( ) � �U.� , . . .4- a i•
a Percolation Test Results Performed i ------- -- -----------------------•- - --- .. 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........................
Descriptionof Soil ----•-----------•---•--------•-----------------==-- ----•--=---------------•--•-•-------------`-----• •- ••----•----------------
._________________________ _ _ __ 4 ............................._____ ._ _.__ _.___.._.._._____.__-
V ________________ _ ___._ __ ._.__..�___ ___. ...
__ . _ _ _ ____ _ _
x --- --------- �s0rr�a- ..._ s- ?�i - -��. . z r .C.e,�✓ Co.
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 Iffn issued e a of heal
Sin :5g --------•••-
/� Date
Application Approved BY *4 %' __-_-___-
Dat
Application Disapproved for the following reasons----------- --------------------- •---- --- --___-•-------------•----••---------------------••-------------
--...--•-••-------------------------•- ----------._._...-------------_----• ------ ------------------•----•---•----•-•-------•- ------------------ --•---=-------------
.Date
PermitNo.-----I............................................... Issued..------•-----....."......-�...............-----------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD <OF HEALTH A
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............ ... .... .. O F..... .. . .. ....
mow,
Trrttftr tr of Tompitanrr
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THIS T T 1', Thak the ividuaZi4wage Disposal System constructed (�r Repaired
Y •••. ------•-•---
G''^ir Instal]er
f , I, Y _...
..
.....
ltas been installed in accordan e with the provisions of Article o LT�,�'e State Sanitary Code as desc e in the'
application for Disposal Works Construction Permit No-------------k�7"------------- dated....... :...�___7��---.._____-_
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS ED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTIO SATISFACTORY.
PATE. w----------------=----••----------.. ........................ Inspector_----- - . ---• �h
THE COMMONWEALTH OF MASSACHUSETTS
BOARD QT7 HEALTH A jro J-;L
... ../ . .... OF.............. 4a �1 ......_.:............
NO: FEE ........ •-........
�t��o� work on�tr�r toat �rrmtt �� ..
Permission is ereby granted------------ -_=-•----- ----•- -•--..._.!.:Sr..........................;.,_.._...-•------•-•-----•-•--•-•-------....-----
to Constr (✓) > 'r ( ) an ividual ew ge D sp sttn.
Street
as shown on the application for Disposal Works Construction r it N .�.____ Dated..........................................
t 1 _
Board Health ,
DATE-------
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FORM 12 5 OBBS & WARREN. INC.. PUBLISHERS
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LOCATION : 3 1 5EWb,C,E PERMIT U0.
_ 60` 75 _ - �` �i ., r rl '� od=ova t.
IMSTQLLER•S I.1�NlE ADDRESS
BUILDERS ADDRESS
Di►TE PERMTT
DATE COMPLI &&ICE ISSUED ; =�_�
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