HomeMy WebLinkAbout0837 MAIN ST./RTE 6A(W.BARN.) - Health 8�I7 �na�M S�. , lO.B ,
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LOCATION SWAGE PE R99 T 130.
VILLAGE
INSTNL V R'S , NAME i ADDRESS
0 U I L D E R OR OAR
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.0A'T'E PE`R141T -1SSNE0 F-0
DATE COMPLIANCE ISSUED ��- �
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
ApplirFa#ion for Disposal Works Tonstrnr#wn Prrutit
Applcation is hereby made for a Permit to Construct ( ) or Repair (3() an Individual Sewage Disposal
011. �'�..a.1.1?....C51........41�........................... ... ---.. ........-------- ----------------------................--------
- cation re
ddress
rl�l. ...........................................
Installer Address
Type of Building Size Lot.............:..............Sq. feet._
U Dwelling—No. of Bedrooms.................................. .Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures •---•---•-----•-------------------------------
W Design Flow............................................gallons per person per day. Total daily flow..........................................._gallons.
WSeptic Tank—Liquid"capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................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........................
�+ ;....:.. .. ._ .. _.
O Description of Soil_____________----- ` --•--- '_..... _ .. ..... ... _.. _
....... r...... ..
W Y____ ____ _________u------------
._._._...._.._._.._....._._.___._._..__._....._..
U Nature of Repairs or Alterations—Answer when applicable___--- Ali_. ...
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iIT .;?. 5 of the State Sanitary Code—The undersigned further agrees no0to place the system in
operation until a Certificate of Compliance has b n 'ssued by the and Df.health.
Signed----. . ..... [........ .............
Date
Application Approved By..... •t . . ..................................................... .......5^(Z- .0 .........
Date
Application Disapproved for the following reasons:................................................................................................................
--•-•-••--•---••-------------•--•----------•••-......--•---•---•--•---•--•-----••--....-------•-•----•------------------•-----------------------•------•-•---•-----•--•...---------------------.........
PermitNo......................................................... 'Issued._&..............................................Date
Date
f
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
gas 1 1 (fY
Appliration for Disposal Works Tonstrurttun Frrutit
Application is hereby made for a Permit to Construct ( ) or Repair ()() an Individual Sewage Disposal
System at:
..... ..._.&Llfa...mix... A.)9............................ ...... .. .---... ..----•----••••• --•-- --.........----•-..................
Location Address or
........�.......d� ...... , <. ..f�.. %:j. ....-• ...... -- ,1 .._.. 5 x J 1 --------•---............---
- -------- -
Owner l Address
t.
a = di�l �t} � ��!!I' ! .) J-���. .. }.�..? t `gyp........... •^ -........................................... --
M Installer Address
U Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
as Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures --------------------•--...-----•--...--•---•----------.---•-.......•---•-----••--•----•----...._..................-••--•-----•--•...-------•----......
w Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............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 ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
�+ [ ; -------------•-•-.......--• . .. -•--•.-•-- ....-- ................................................................................
r
.O Description of Soil............ / C t _ `
----•- .•...••••-••-•••-•--•-•-••-------------•-••..........-•---.....-•--•----•••......----•-
w
�( tea. �... f----••••-•••-•---•-----•••--••••--------•--------•-••-----•---...-----••-----•-
�,.
U Nature of Repairs or Alterations—Answer when applidable..._._ .......
. =.JI:_/..Ct ....
......................................................................................................... ...........................................
Agreement:
The undersigned agrees to install the aforedescribed'Individual Sewage Disposal System in accordance with
the provisions of ITT E, 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 bf health.
.._Signed....--t.......y._..� , r....------•---- = �---•---•-•---
,,.,ter 1.._._..... Date
Application Approved BY tea'"[ 1 -�'a c .•. ................................................. / ::140.-----------
Date
Application Disapproved for the following re ons:---•----••-••---•--•-••-•-•-•-----------•-------••-------••---•••-•---•....••------•----•••...............•-_._
.................................•-------•--•-----••-------...------------•-----.........----•-........--•---------------•---••-----•••---•--•-•----••-••-----•••--• ...................................
Date
PermitNo......................................................... Issued.......................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
f�w; : ......oF.... ,�,- 7' . ............................
(Irrtifirab of ToutpliFaurr
THIS IS TO,CERTIFY, That the Individual Sewage Disposal System co st�ruc.ted ( ) or Repairedstaller
( )
at......... ,1•'?/"ff1'7 �/ / � . fr•I, ,-rr� .)11,- �.,�t�i_1 /..} r11r r
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.___06—!t,�.$............... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................•---••-•-----.......--•----•-•----..............:.............. Inspector.................................................................................... ri
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........)rAf.1 .:1..7...........OF....Z_--�>..)1 �
No. ,r:.-: �.> ... .....................'
Disposal,Works Tonotrudion Vanfit
Permission is hereby granted...._,; ` •i�!!%l�j. "7;A"-1-~ t- ;1_t .......................
••. ---t ......--••-•-•----
to Construct (, ) or Repair (/Y) an Individual Sewage Disposal System
at No.............14),t -x' �<' 7r� l l< ' 1...�f
-
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
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Boar ealth
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FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS