HomeMy WebLinkAbout0202 LAKE SHORE DRIVE - Health aC)a � W-zvo-
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No- Y1._-_.... F��... ...._
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® 9F HEALTH
0"
o, : --- -------.OF...-.. ------------------
, ppliratarrn for Disposal Works Tomitrnrtion Prrinit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Syst at:
Locati Address 2 Lot No.
wner 1 f
w
Installer Address
Q Type of Building Size Lot._ __/�_______________Sq. feet
U �/
Dwelling No. of Bedrooms_____________::!?6....... Attic ( ) Garl4age Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................. Showers ( ) — Cafeteria ( )
dOther fixtures --•--------------•---------•---------------------------------------------------------------------•---
w Design Flow__________________________ ,,gallons,per person per day. Total daily flow____.____._. .............................." gallons.
---------------------------------------
--=-------,�,,
x Septic Tank—Liquid capacity,A(gallons Length................ Width-_________.-____ Diameter--------- Depth----------------
Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No......2 ______ Diameter____ ______________ Depth below inlet.................... Total leaching area_.________________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---------_.........
.___.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_____________________-__
..-•---------------•-------------------------------------
ODescription of Soil.............. -+ ` � -------------------------------------------------------------------------
U --•--••-•-•----••-------------------••--•••-----------•-•••••--•--••-•-••--•------•-••----•---•----•-•--•---•-•-•---•------••-•----------------•••----•---•-••--••----------------••---••--------------
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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 agr not to place the system in
operation until a Certificate of Compliance has been issu d the boar health.
S•
t - -------------- -- ------••-------------------
Da
Application Approved BY '� ------ � 'z _?✓
/Dace
Application Disapproved for the following reasons:..•----'----------------- -•----•---------•---------••----••----•---------------•-------------•-•----••••••-•-
_________________________________________________________________________________________________________.________.___.______._.___.___.___«____________.............. ______r__....___________________
Date
Permit No. ---------------- Issued--- . `..1 a
De ------
_- t------ -----
JI
No... FED... .. ...
THE COMMONWEALTH OF MASSACHUSETTS
,. EOARDRF HEALTH J
a .. A r
' `D
Jkvv i.ra#iou for Diipa, al 10orks Ti amtrur$i.ou. Prrmit
Application is hereby made for a Permit to Construct (' ) or Repair ( ) an Individual Sewage Disposal
r ,f
System at: 14
...... ; A -------•---- --•-------------- -•••----
17 al,
4...........;......
ocatin Address E •r Lot.No.
-___ .
p Addre#w
Installer Address
Type of Building Size Lot__A_ .�Sq. feet
Dwelling e No. of Bedrooms............ ........................Expansion Attic ( ) ' Garbage Grinder ( )
`1 Other—Type of Building No. of persons____________________________ Showers — Cafeteria
Other fixtures -------------------------------------------------- -- - -
----------------------------------------
W ___________ gallons. person per day.-Total daily flow._.,.........................................gallons.
Design Flow____________________
WSeptic "Tank—Liquid capacity, gallons Length---------------- Width_._.__.____.._._ Diameter___.___'_..__. Depth---------
x Disposal Trench— o_............___-----_fit%idth____________________ Total Length.................... Total leaching area___..._____.._______sq. ft.Seepage Pit No..... --------_,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__................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_____._.,__.___________.
--- -------•------- = ,
ODescription of Soil------------ '" ' `----------------------------------_-._....__....------"---------------'-.
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 agr s not to place the system in
operation until a Certificate of Compliance has been issued by the
. i bo d health
t
II
'Si e d D
Application Ap � '
proved BY- P
Date
Application Disapproved for the following reasons:........................, ----------------------------------------------------------------------------------
-------------------------------- ------------•------------ ---------------------••-•-----•-•-••-••••--_.._..---------•--•------------------•--,-•-•-------•-_._....-----•-------------•------•---------
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
4 . ................
. ..:.............OF...... :%'..4rt�te�
Tntifiratr of Tom iianre
' THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ) or Repaired ( )
by -- --- ----- ---------
4i
g j ller
%,has been installed in accordance with the provisions of Artie XI of,The State Sanitary Code as de 'bed in the
application for Disposal Works Construction Permit No________________ _____ __ .._.._ dated_,_�;�X. _7 __7 ..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM-WILL FUNCTION SATISFACTORY.
`:DATE•-------•---------•--•----•----...---•----•-------------••------•-••----•------- Inspector..............................................................----------------
Lk
THE COMMONWEALTH OF MASSACHUSETTS
�. BOARD OF HEALTH
' .� �3:....... ....O F........ "fit -'--'-----....
No. -
._.__. FEr ..................
Permission is hereby granted---•- ---- J�-w'--- -----••----•--•- =--- -----------•--•---------
t6lCons .uct or R a•r ( )p an Individual Sewa ,e Disposal stem
at 4
Street '
as shown on the application for Disposal Works Construct_ rmit !. _ _ Dated_ �s_ _z'----
- --= -•_-- ..... - .............................
Boa d of Healt
DATE----------------------------------=----------------------------------------------
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS -