HomeMy WebLinkAbout0150 CONNEMARA CIRCLE - Health (2) "t1bs- agn- i
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No..
THE COMMONWEALTH OF MASSACHUSETTS
\' BOARD 0 HEALTH
------_--
Vpfirafiott -for RiiVoiiat Workii Totouttawn Vamit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at: Y_ ���c_4 o- -V 3
......................... ................................ ....... . ..........................................................................
Location.Add or Lot No.
re s
............. k.21..I............................... .......
Owner Address
C .................... ......... .. ..............................................
.......................
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms----
--- -----------------------------Expansion Attic Garbage Grinder (jo)
Other—Type of Building __fAYNI��------ No. of persons.--------------------------- Showers Cafeteria
PL4 Other fixtures --------------------------------------------
W ............................................gallons
--------------------------------------------------------------------------------------------------------
Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
P4 Septic Tank—Liquid capacitv__101f___gallons Length________________ Width-.___-___..--. Diameter_...-_..._.--__ Depth.__._.--_-----.
xDisposal Trench—No..................... Width------______.__-___- Total Length____-___-........... Total leaching area----- ..............sq. f t.
Seepage Pit No..................... Diameter-_________--_-_--_ Depth below inlet._...____........... Total leaching area...--------------sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by....................I..................................................... Date----------------------------------------
aa
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--.-----__-.-__----____-
...........I---- -------- -------------------I.........................................................................................................
0 Description of Soil----------5.-nq-----!kn..... --------------------------------------------------------
----- --------------------I--------------------------
U ........................................................................................................................................................................................ -------
------------------------------------------------------------------------------------------------------ -------------------------------------------------------------------------------------------------
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 agrees not to place the system in
op eration until a Certificate of Compliance has been issued by the board o4 health.
Z Sig
ned- .....7....... . ............4-------------- ............Da.t.........3_
ate
0/a
Application Approved By-------------
---51
Application Disapproved for the following reasons:................................................................................................................
................................................. ............................................................-------------------------------------------- --------------- ------------------------_
i— - —Rate
.2
Permit No......................................................... Issued....... ......... ... .......
71t.�li....................
Date
------------—-----------------------------------------------------------------
No....' `5 F��...... ....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF, HEALTH
1
Apphrati>o n -for Uiiipuiittl Workii Cnomitrurtimtt Vami#
Application is hereby made;for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
. • ¢` -
Location:Address -or Lot No.
..... .+-------------------------------"------- ••----•-----------•....--------•...•-----•••--•-------"--•------------•---------•---•------
/_' �JFq��' �q Owner , Address
a ....-- --
Installer Address
Type of Building Size Lot-----------z................Sq. feet
U Dwelling No. of Bedrooms._._-___ _____ _ __ _____Ex Expansion Attic Garbage Grinder )
g— P ($ ) g
Other—Type of Building _ t!qt".--.--_-_--- No. of persons___________________________ Showers (/ ) — Cafeteria ( )
Q' Other,fixtures ---=-----=-------------------- - -- - --
W . Design Flow............................................gallons per person per day. Total daily flow _..__ ...__..___.__..: .,_-gallons.
WSeptic Tank—Liquid capacity-le---gallons Length................ Width........-------- Diameter_--.- Depth---._-,-__---.--
x Disposal Trench—No- -------------------- Width-------------------- Total Length.................... Total)eaching,area---------------------sq. ft.
Seepage Pit No..........:.......... Diameter-------------------. Depth below inlet.................... Total leacliing area.:__-.-_----___-.sq. ft.
Z Other Distribution box (- .::'r);• Dosing tank ( )
Percolation''Test Results `':Performed by------ - - ----------------= ............................. Date...........I----------------------------
Test Pit No. 1................minutes per inch Depth of "Pest 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----------.. i........................................�'` i..•--••-----------------'•--•-- - -
U --•---------------------=-•--------------
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 agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of-health
Signed.- d` rg 1 ..
�•�'-
- - - ..w F j ,.�•�ybt•"�*,�`+^ b,:.w Date, r
A lication Approved B �"° - _ _ .......k �'
' PP , <
PP Y t �'' s// r to
Application Disapproved for the following reasons:................................................................---=-'--•-•------------ _------- "-----
..............='----------------------------------------------------------------------------------------------------------------------------------------------------------•-----------------------------
Date
PermitNo.......................................................... Issued.........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF. HEALTH
..............0 F.......... �...:...:. ..<
F CTrrfif iratr g r
T� ST0 CERTIFY41� rthe Individual Sewage Disposal System constructed ( ) or Repaired ( )
Installer
a r
------ -- -- -
has been installed in accordance with the ovisions of :Article XI of - he St� Sanitary Code—as described • th,,�
�� �` _.. �1 Itea _
application.for DisposalWorks Construction Permit No ____ __________
'THE- ISSUANCE OF THIS•CEaTIFECATE SHALL NOT. BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE. Inspector.......--...........................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
I ,f
FEE
ClIonlit 1Wat
Permission i he y granted------- --- ,• - --- -- --
_
to Construe oepatr ( ) an.,-Individual Sewage Dtsp sal Syste
at No..• e Via€. { - --- ° E t -------- --- -- ----
b
Street �^`m � ate. -
as shown on the application for Disposal Works Constructio e mit N . . _-_:_ .._. Dated----- .... _ ----_.7.,X ___.
Board of `ealth
DATE ---- -
5 HOB WARREN: INC..& WARRE INC.. PUBLISHERS
FORM 125