HomeMy WebLinkAbout0289 LAKE SHORE DRIVE - Health � ,� T7
No.........
F�s..... :s .......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAN H /:
/1a � .......
tJ /" Appliration for Disposal Works Tonstn.rtiun rumit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at:
�� 1 .. .. _..• E' ....d �Y e............................ ...................................../Gl✓S.._........
Lo n-Address or Lot
- ... ..
Owner
....... ------ ----------------------------------------------------- -------- ..... e.........................................
Installer I Address
d Type of Building Size Lot.27e_�k A---..Sq. feet
U Dwelling—No. of Bedrooms........._r�.............. .Expansion Attic/yo Garbage Grinder is
'4 Other—T e of Building No. of persons............................ Showers — Cafeteria
P4 Other fixtures -----•---------------------------------------- -----
---•
w Design Flow.......��..........•..........gallons per person per day. Total daily flow.............. .:._.................gallons.
WSeptic Tank—Liquid'capacityM�q..gallons Length.Za.`r.. Width....6..�.__ Diameter________________ Depth....
x Disposal Trench—No..................... Width.................... Total Length......_.... �..... Total leaching area....................sq. ft.
Seepage Pit No....../............ Diameter...... .......... Depth below inlet.....dry....-.......Total leaching area.a.?.!....sq. ft.
Z Other Distribution-box Dosing tank (XP
Percolation Test Results Performed by..___._ r_.........r'±__ ✓.._----Z.. :2�............... Date.........
a
Test Pit No. I...&o.Z......minutes per inch Depth of Test Pi ....... .:..... Depth to ground water../.Yo..6,,, , � -
Gi, Test Pit No. 2................minutes per inch Depth of Test Pit-------- Depth to ground water........................
u+ ----------- j
0 `Description of Soil............. Qst..�...... ......... G------•--------• ......------------.--•----. ---------- -----.......------
x
U
ow
UNature 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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b4en issued by th of health.
Si d .................
Date
Application Approved By....'�,P� •• -----•••--- ............................... x
Date
Application Disapproved for the following reasons:----•---------••----•-••--------------------------------------•-------------•--•-••-•--••-•-•...•-•---........_
-------•.........................•-----------------------------•-•--•----------------------•---............----•---------------------------------------------------------•---------••--••-------...._.__.
Date
PermitNo....................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
:....... ........OF...............: '... .....................................
Trrtif irate of Tuntplianrr
TH I/, T ERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
by.. sti.:
Inst /.x� —
has been installed in accordance with the provisions of Tod-a5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No._ ....��. ................ da.ted__... __`.t ". .........._..•._...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
1'7
FEic..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAL
....... ................OF......... ...... ............. ................
�vvftrafton for Disposal Works Toutitrurtion Vamit
Ajp lication is hereby wi�a%e'Y for. a,Permit to Construct Kor Repair an Individual Sewage Disposal
Syqtem.qt: N
tilt e JAVIer....Pkl.y.e..................................... .................. ... .... ... .. .......... ......T7hy
On-Address e " or Lot Ngl�
e � 02 or
L .......
....................... ................................... ................................................................................................
Owner Address
..................................................................................................
Installer 7 Address
Type of Building Size.'Lot.......7,..A../Aw.Sq. feet
oms.........S!�!............................Expansion Attic#0
Dwelling—No. of Bedrooms...._.... Garbage Grinder (Xcp
P4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
P4Other, 6xtu es .................................................................................................
Design Flow------- gallons per person per day. Total y
......................... - - Y.
- -------
-....q..gallons Length_r,(.!r... Width:_....,.._ Diameter________________ Depth::..-."..--
Disposal 6."....
9 Septic Tank—Liquid capacit/ ------
Disposal Trench—No. .................... Width -1-------------- Total Length...........,"I..... Total leaching area....................sq. ft.
3 Seepage Pit No....`1............ Diameter......!9'- Depth below inlet...:A.......... Total leaching area: V./....sq. f t.
z Other DistributionDosing a box 19 t _Percolation Test Resulti, Performed by. ..._!_"__.. ......... ........ ... Date.......
1-.4 1� .. .....0................
Test Pit No. I...05t......minutes per inch Depth of Test Pi --------0-*....... Depth to ground water_............�"�._.
Test Pit No. 2................minutes per inch Depth of Test Pit...__.........._.... Depth to ground water.....................__.
i-------------- ------- -------------------------------------------------------------------------------------------
0 Soil._ ........................
Description of S I-------------------------------------------------- -------------------------------------------------------------
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 T IT 1Z- 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Si jd*............................................................................... ..........................
60-.?-;YK o.
ApplicationApproved By../e....................................................... ............................... .......................................
Date
Application Disapproved for the following reasons:...............................................................................................................
........................................................................................................................................................................................................
Date
PermitNo......................................................... y IssuedL......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
at a
..........................................OF........... ................. ..................................................
Tatifirate of Tompliaurr
FY, That the Individual Sewage Disposal System constructed �) or Repaired
by.. ......... ... . ..... ..... .................. ... . . ..... ..................................
a)�-----------------------------7-------*"-------*----------------------------------------------- ..........---_------------ --------------------------------------------------------
has•been installed in accordance with the provisions of f
The State Sanitary 92dyz in the
application for Disposal Works Construction Permit No......................................... dated-...............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD C?V HEALTH
. .............
............. ......................0 ...........................................................................
No......................... FEE........................
Map 5 tnodrat ion ,Vamit
Per'miss* 1 hereby gryted -- ----- ....... ........................on s
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t
to Con n In is
;6 -/- Y,
AA"Qr RV V1 t�-' IV r A
atNo............................................................................................................................................ ............................------------
Street
. /'/"j A zr-
as shown on the application for Disposal Works Constructionit No-------- Dated rml .................................. ......
T....
............................ .................................. ....................................
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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{ �F` r, •, ,�'O ,• �L(M OF Mks �a OF
NK CONERY 5 TRENT(M ST,
o� ,#' FRANK FRANK �, HYANNIS. MASS. OW S s c� !C/- .5 C Ale r 3"7 a �t .4
CONERY o CONERY raIVMD ZNQTH caR a LAND SUMtVOP
L / No. 6573 No. 6232 40
90� GISTE c�� crsTf.P p' LE t tW �� 1R'. c 1 Z1,78
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