HomeMy WebLinkAbout0306 LAKE SHORE DRIVE - Health 0�,-0 Dq
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No....... - F�a... .................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEAL H
.. . .. --------------------------------
Appltratiorc for Mipnsttt Works Clan strurtion rumit
Application is hereby made fora Permit to Construct (1/) or Repair ( an Individual Sewage Disposal
System at
...... . _ A7------ ..................................
Location-Address or Lot No.
O.
.............................................. -•----------............••........._.. .--------------•••-•-----••.........................
Owner Address
--------------------------------------------
Installer Address
dType of Buildin j Size Lot...2_—J_X_.�_.<Sq. feet
V Dwelling No. of Bedrooms___----------A/..........................Expansion Attic ( ) Garbage Grinder ( )
`., Other—T e of Building No. of persons............................ Showers — Cafeteria
a' Other fixtures __. ................................................
W Design Flow.......................& __...... gallons per person per day. Total daily flow.............. ..............gallons.
WSeptic Tank 7-Liquid capacity _gallons Length................ Width---------------- Diameter________________ Depth................
x Disposal Trench—No..................... Width.._ to th____ _-_-_ Total leaching area....................sq. ft.
3 Seepage Pit No.__..... __.._ iameter___ _�`-w. epth e 6w inle •___________________ Total leaching area______________._._sq. ft.
Z Other Distribution box (/') Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date---------------------------------------
aTest 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
a water_.-.-•-_____________.__.
- ---------• - -- -- %t �--- --
C
4
O Description of Soil---------
w
UNat-ire 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 hakbeissued by he rd of health.gnedDate
Application Approved BY--------------- ------ . 2- f
Application Disapproved for the following reasons------------------------------------------------------------------------------------------------------------•••--
Date
PermitNo.-•-•-•---•-•••-•----•---•..............•--........•----- Issued..-----�/ _----, 7-----..---•-
Da
No...... ........ FIaE.. .......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OE HEAL H
O . - OF..... ... .. ..................................rr
Allptiratiaatt for Roposal Works C omitrurtioat Vrrnfit
Application is hereby made for a Permit to Construct (41) or Repair ( ) an Individual Sewage Disposal
System at• -
14
9 e
; ... . . .......4 ...................................
Location-Address or Lot No.
= = - .;.............................................. ------ ----- ---........---------------------------------------------------------...---
Owner Address
Installer Address
UType of Building Size Lot.-2.4f.�. _g ..,Sq. feet
Dwelling�No. of Bedrooms............ ----------------------------Expansion Attic ( ) Garbage Grinder ( )
`1 Other—Type T e of Building .......... No. of persons............................ Showers — Cafeteria
a YP g ------------------ P ( ) { )
a' Other fixtures .._
----------------------------
Design Flow....................... gallons per person per day. Total daily flow..............,._. gallons.
9W Septic 'Tank�Li uid caP citY/rZ 11_. allons Length---------------- Width................ Diameter---------------- Depth----------------
x Disposal Trench—No. ......... ......... Width............ . Total ngth.-�� .. ..... Total leaching area.-__-___•__..______-sq. ft.
Seepage Pit No_____ ________ Diameter...�d.�l"' __ ep h l in e6f..... ___.__...... Total leaching area.-----------------sq. ft.
Z Other Distribution box ( Dosing tank ( )
Percolation Test Results Performed bY-------- ------------------•--------------•-•-••-------•-•----•......•--•- Date----------------------------------------.
aTest Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water______________________
0�4 Test Pit No. 2-•-•.-__----_•.-minutes per inch Depth of Test Pit.................... Depth to ground water______________________
O Description of Soil-------- ,-------------
U ------------------------------------------ ---- ------
W
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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be n issued by the board of health.
igned.._. _�: -------""''`---- ----------- ----� � a
a - Date
Application Approved B
PP PP Y ' e� --- . -- - y
Da Application Disapproved for the following reasons: •--•-- -----------07- ----
•--•----------------•---•--•---•-------••----..........-•------------•-•-----------------------------•-----•-•--------•-•-------------•••-•-••••••----••••--------------------•-•---•......---•••••---
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
e ��.. .. ..............OF...............� .: �r'1 ., ................................
�rrtif irate of (11aaaatph aata
THIS IS Z
t CER Y, That the dividual Sewage Disposal System-constructed ( ) or Repaired ( )
by------ = �`! --- - --- - -- -=
r In ter ,�-• � -
) °� -
has`been installed in accordance with the provisions of Article XI of The State Sanitary Code s described in the
application for Disposal Works Construction Permit No..... ..... . ............ dated.-.__;4=__:._ _. ��
,. ;®;,
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 Pf HEALTH
O F.. 'f }
No. - FEr ......T'-......
�i>a�aa�� �• ,� C� �trixrfi��c rrattit -
Permission is reby granted..... ... . s�
ras °.=. -titi-o gip"
to Construct ( or Repair ( `) n I dlvidua age Dispos System 11
f
a . .. ........ 4• --- f""
Stree
as shown on the application for Disposal Works Construction Pe it No- OF ______—j�. Dated---2--- --:--
------ ...... ...���'-- ........................ -
. r Board o Health
DATE = `=A-- -
FORM 1255 HOBBS &.WARREN. INC.. PUBLISHERS ..