HomeMy WebLinkAbout0028 BUMPUS ROAD - Health (3) Gu.rn pu,o
O 0 3
No.. _. ._.. .................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD) O HIEAL�H
t--_.....OF...... .:... ......_.....
+ , pphrtttion -for 43iiivinitti Vorkii Tonfitrurt- n osal rrutit
it an Individual Sewage Dis
Application is hereby made for a Permit to Construct (, ) or Repa ( . ) b p
System at:
---.A _ -•---. •_••••
- _-_...___.••-•
.1 ton ess or Lot No.
--- - -••------ .................. ' - .....................................
Owner , ` 4 res
Installer Address
Type of Buildin�/ Size Lot............................Sq. feet
U Dwelling�No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
PL4 Other—Type of Building ____________________________ No. of persons____________________________ Showers ( ) — Cafeteria ( )
a 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 .................... Wid i__._______ f�otalL th___ _ Total leaching area.._..._...__._.____.sq. ft.
Seepage Pit No_____ ________ Diameter. epm et_________.:__._..___ 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..._____._.___.__-_____.
fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.......-----------------
-------------------------
•------ -- ----------------- ------------------------ - ........_...............................
O Description of Soil--------------------------- ------ -- -----
--- -- -----
---o----------- -----------------------
x
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 tI of the State Sanitary Code— The undersi ed further agrees not to place the system in
operation until a Certificate of Compliance h, sued b the oard of health.
Signed- ! - ------------------------------------------------------------ --------- -!!`_�7.3
Date
A lication Approved B .----....--•--------- -- --- -- -. l - . -�------- -----------1� at /
PP PP Y Date
7--
Application Disapproved for the following reasons-................................ --------•----------------------------------------------------------------
..-•----•---•-----•----•___._---•-----------•-------------•----•••--•--••-•••••-•-••-••-•----•-•-•----•-•••._.__-------------------•----------•---••...._..-----------------------•---.._----------•-•--
Date
PermitNo......................................................... Issued............................... ..................
Date
�.
No.-" t.• F�� r 614
....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEA TH
. OF. '�
Appliration -fear Bifipoiial V Varki Tomitrurtinn Urrutit
Application is hereby made for a Permit to Construct ) or Repair an Individual Sewage Disposal
System at: l
. ---•----•-•-••-------•----=--------------------------•-----•
tion- dres Ls or Lot No.
:w ----/�
Owne dyes
a .._.....
Installer Address
Type of Building Size Lot____________________________Sq. feet
v Dwelling_"O. of Bedrooms--------_-----------------------------------Expansion Attic ( ) Garbage Grinder ( )
04 Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures --------------------------------------------------------
W Design Flow...................................:....__..gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity------------gallons Length................ Width---------------- Diameter-----........... Depth..--------------
Disposal Trench—N ..................... Wi h .._...... __ *, otal L n th._ /__. Total leachingarea....................s ft.
r•, �
Seepage Pit No. --------- Diamet, p.r a met ---_---- Total leachi g area------------------sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed bY------- -------------------------------------••--•...--••••------......-- Date----------------------------------------
a Test Pit No. 1----------------minutes per inch Depth of "lest Pit-------------------- Depth to ground water.._--___.-._-_."--..__..
�14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water............._."-----__.
04 -•------------ -----------------•--••----- --•------------------------------.------
0 Description of Soil------------------------- ----
V -------•-------------------•---------------------------•-•---------•------------•-•---------•••-------------------•-----------------------
V 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 under ned further agrees not to place the system in
operation until a Certificate of Compliance has-b sued by the oar d of health.
Signed-- ------
Date
Application Approved BY = ;-- ` --------- ------=Yf'-. .:
Date
Application Disapproved for the following reasons---------------------------------V.................................................-------------------------
----------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF EALTH
........OF................ .. .... .....................................
�rrtifiratr of Toutplitttta
TH S O CEPT l Y, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by / ---- ----=`------------ ----------------------------------------•----------•--------•--------------------------•--•---------•---
Installer
at-------------------------------------------------------------- --------------------------------------- --------------------------
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described 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 W14 FUNCTION SATISFACTORY.
DATE----- a/7---------------------------------------------- Inspector---- ------------------------------------- ...................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD °•,O HEATH .
No... '.. FEE-.................
i u r C rrtt trttrti at rr it
Permission is hereby .granted ----------- -------------------------------- - --------- ----•---
to Construct ( or Repair ( tn Individual Sew geD al Systemat No. ,, ' �- " � ....-- a
9 -------- - --- ---
Street l
as shown on the application for Disposal Works Construction P No ... atepppd
------ -.-. --- -•_•-- •-___.".___ - . .... .__.b
Board of Health.
DATE---•--�=-� j
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS