HomeMy WebLinkAbout0025 CROSS WAY - Health (2) as CrDss uxZ7q.s �3
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
---------OF..........1.4an, .......................
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Syst at: _
.........
-Address i 4 or Lofie�il
.................CJ --ICE:-[�l•�'/ Cal� �.^_='-(- --------
ner Aress
Installer Address
d Type of Buil •ng Size Lot............................Sq. feet
U �NO. of Bedrooms.... ......Dwelling -__-__-_____-----_---.Expansion Attic ( ) Garbage Grinder ( )
. ..
Other—Type of Building ----------------------- No. of persons---------------------------- Showers — Cafeteria
Otherfixtures . --------- ----------- ---- ------------------ ------- ---- ------ -- --
Design Flow..................... .._._. _gallons per person per day. Total daily flow___________ � .... ..._..gallons.
WSeptic T tnk/—Liquid capacit� gallons Length................ Width................ Diameter_____..._.._____ Dehtll_._.._..___._...
x Disposal Trench—No---------------------- Width.................... Total Length------------------.. Total leaching area--------------------sq. ft.
Seepage Pit No--------------------- Diameter-_._.___-______-_-- Depth below inlet.................... Total leaching area------------------sq. ft. a
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed bY.......................................................................... Date_......•-----------------------------"
a
Test Pit No. I................mtnutes per inch Depth of Test Pit-------------------- Depth to ground water..--___-_._----..-.-----
G% Test Pit No. 2................minutes per inch Depth of Test Pit.................... De • to ground water-----.----------_-_..._.
--------------------------------- - •. •. .--- . - ----- -- - -
O Description of Soil-____."__. : �
-- ----------- ( - -
•.
U Nature of Re irs r Al orrs—Ans er w en aRplicable.._` �!-� - �: _._ _ '%tee •. _ .... ....r_.______ __..
-----------------
Agreement: Goa
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The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accor ance with
the provisions of Arti& XI df 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. .. . •••-• ........ ---------------
Da
Application Approved BY-------- -4 �------ :. -- -- =� � -------- le
Date
Application Disapprove or the following reasons: -7'._- ...... - -__-------- ��,�Qe
•-------------------------------- ...
i
PermitNo......................................................... Issued...........................................""_
Date
0 r
No......................... Fss...........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.j
O F.........
_._ . - ..............
Appliratiutt -for 4%ip al Works Towitrttr i n Pgr utit • ,
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
� - ' ..
l cation•Address or Lot-No.
,r U �jd
-- '•-2----- .•....... ......: .:.. = ,=---...---------- Yes*
r� u �r
O ner Address s�
nstaller Address
QType of Building, •---� Size Lot----------------_--_-_----Sq. feet
U Dwelling/ZNo. of Bedrooms.---_-___-�,-_'- ----------------_-__-Expansion Attic ( ) Garbage Grinder ( )
P-1-, Other—Type of Building ---------------------------- No. of persons.--___-----_---_-_--_----_ Showers ( ) — Cafeteria ( )
a'' Other fixtures ..................................................
Design Flow.......................... _._._-gallons per person per day. Total daily flow............ Cr .... .......gallons.
WSeptic Tank-Liquid capacit�1�7_ 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........................................
a Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water..,---------------------
LT. Test Pit No. 2................minutes per inch Depth of Test Pit..-_----__________ De nth to ground water_-.-..---__-.--.-_.--...
_- --...--•-------------------------------------------------
D Descri tion of Soil._...--.-" �-
x 1 I f---------• - -- --
------------- --------e : . ------. ......-•----
x v / -
--- - -- -- ---
Nature of Re <irs,or AI e . .tons—Ans er w en a livable._._. ............ .. _.________ :- - -
`�`
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- r Mtn ti =4 ,t 1 1/4Vf
••. ------ •-----------D-------••---------
Application Approved By -- -- ` sue y
Date
Application Disapproved for the following reasons------------------------------------/----------------------------------------------- -------------------
---..._-----•-------------------•---•....-•-•--------------------------------------••---------•---------------------------------------•--••-------------------------------------------•---------•-------
Date
PermitNo......................................................... Issued...................... .................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
?! r .....OF............ Wr + / eC !..................... tzt/.. .: ..............................
mwrrtifirttte of fiTlImplittttrr
THIS I 0 CERTIF hat the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by-------. .. -�j/--------- 1 ` j-//.-i-�✓ ............................................................... ---------•----- ...........................
...i'f[/ / (��A I�.i _l l,Y'F !Il.ft._ �- --- 7 - -
at... ,i2. ---------------------
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........ ....:�4................... 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 "' ���-- �f
BOARD OF/ HEAL_T_H
_3 v / f
.....-e.-:�•�ti.. . .er, t
No......................... FEE....-----•--•----------•
Dinvolia r (IT rurtion Vamit
G. G✓_ -
Permission is hereby granted.......
= = ........� .
to Construct ( ) or Repair ( � an Individu Sewage Disp sal System /-
at No..7 it. ' - . All, ��C �ti Pr�w�v t�,�
Street --
+'3
as shown on the C.
application for Disposal Works Construction . r it No �'t _ __ Dated------------------------------------------
Boar Health
aP�
DATE.... ...... ---------------------------------------
FORM 1255 ORBS & WARREN. INC.. PUBLISHERS