HomeMy WebLinkAbout0000 FALMOUTH ROAD/RTE 28 - Health (2) ��almo� (mod� t�anni s
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® .... . F HEAL.T
11' - OF......
Applipativtt for DiamialAviarkii (foustrurtion Pprutit
Application is hereby made for a Permit to Construct ( ' ) or Repair ( ) an Individual Sewage Disposal
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•• Lo ' n. d e ort, o.
_ Owner _ _ d s
� ...�/.. .... �..- Installer. ................................. ............................................Address...........; ......._._ ..._._......--
UType of Building Size Lot-._.2 x_`.7 isT.- eec
Dwellingf-No. of Bedrooms. . . ....._...........................Expansion ttic ( ) Garbage Grinder ( )
aOther Type of Building .: '. .: _ No. of persons......... .............. Showers.4j-- Cafeteria ( )
1 Other fixtures ----------•-•--••--•-•••--
-..................
W Design Flow............................. _________ gallons per person per day. Total daily flow :____... ._ ........._...._.gallons.
WSeptic Tank�-Liquid capacityl-------_gallons Length................ Width_............. Diameter................ Depth................
Disposal Trench—No..................... Width _. T t���Lenj i...q/............ Total leaching area....................sq. ft.
x Seepage Pit No....(............... Diameter.:°:_ . ....._.I.) elw n et......._............ Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water____________--__-______--
5; r ��
[Xq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..................
Description of Soil. ..... ,0 � .... � L�__ _ `rt^ c:': <Q
x ---- '
U //r - .
U Nature of Repairs or Alterations—Answer when pplicable.....________------- _......................................``
A
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage-Disposal System nS'�cq �Tnce with
the provisions of Article XI of the State Sanitary Code—The undersign further agrees not to plac4e system in
operation until a Certificate of Compliance has be y the o healt
Signed- /�----- - .... .._. Z � ............'
�� > Date
Application Approved BY =f ��.� . . .... :..... .............. ...... I.., .�..�
to
Application Disapproved for the following reasons---------------------- -------------------------------------------------•-•----------------•-•-•--------.--•-•-
..---•------•---••--......-••--------------------•-------------.....-•-------------.......---••-•---•••--
Date
PermitNo.......................................... Issued..............---_.................. ..................................
Date
....... Fnx... r:.................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
... OF-
Ty
......A ....................
Applir6ativu far Uhivinial Works Tonstrudioat Vrrutit
Application is hereby made for a Permit to Construct ( 4) or Repair ( ) an Individual Sewage Disposal
System at:
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ion
.................� _Lo. ...........
.... ...... ... �r o Lo ....
Cv'`,
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Owner Address
...............................: Installer......................................... ............................................Address ........._...._...........................
UType of Building Size Lot::..........................Sq. feet
Dwelling No. of Bedrooms................................:...........Expansion Attic ( ) Garbage Grinder ( )
Other ,,�
p., --i�Type of Building ____________________________ No. of persons............................ Showers ( ) —.Cafeteria ( )
p-I Other fixtures ......................................................
Design Flow......................................... gallons per person per day. Total daily flow............................................gallons.
1� Septic Tank --Liquid capacity�� .gallons Length................ Width......_......... Diameter......_., ..... Depth................
x Disposal Trench—No. .................... Width.................... Total Length-------------------- Total leaching`area---------,..........sq. ft.
Seepage Pit No....Z............... 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. I................minutes per inch Depth of Test Pit.................... Depth to ground water...•....................
fz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water___---_-____-__-_____--.
1:4 -• .....
O Description of Soil----------...................'r` s" .. i
x .....
l• ---------
.-------•---------•-----------------------------•--•• -•--••-- -•••--•. •••-•-•••-•-••----•----•-----•----••••••••..................--••-----• ,
U .
W --•--------------------------•---------------•-•------- 5 .,
U Nature of Repairs or Alterations—Answer when applicable.._.... ...........................................
�i
--------•---•------•--••------....--• ••.....................................................•------•-•--=-•---•-----------•------........................--
Agreement: J ^<�lam`' z ;`,5•
The undersigned agrees to install the aforedescribed Individual Sewage Disposal Sys i iu,4Ccordance 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.
Sied...--•--•.....................•-----•-•--•-----•-••...----•-•-----•-•----•---•-•--- ...
Date
Application Approved By.. ;-•--_:..
Date
Application Disapproved for the following reasons----------------=-----------------------------------------•-----...........--•-•------•••-•-...........--•..I....
--••------•---------------------•-•--•••-•••••-••••••-•--•-•--•-••••-••--•-••••._........----••-••---•------•-•••••••--•--•---------•-•-•••••••••••••••••••• ...........................................
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
r � r
.............oF.......... .. � . > ... .................
Tntiftrate of (guutpliFaurr
THI SS Tgg CERj FY, Th e Individual Sewage Disposal System constructed ( 69�eor Repaired ( )
�
at-- e n -- le--- • C" 't -------------------------------------------•------•-----------------
has been installed n accordance with the provisions of A icle XIe-t-
f The State Sanitary Code as described in the
application for Disposal Works Construction Permit No................. a____:.___. dated _yt`. ._..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.....('�" ._`�. . _.. --3.._...---•---------------------..... Inspector-- --- ... ...........--•--- Y.----
THE COMMONWEALTH OF MASSACHUSETTS
.. BOARD OF HEALT
. ............. ....f ,�........OF..........
a
No.... .. '..... FEE.
�1�1,���. t,
Permission is hereby granted.... -- -- --- -- •---------- . _.....' ....................................................
to Construct ( or Repair ) ndividua.l S r D•-`o 1 Sy m _ l 7_ 2,
at No...=..,�. .�.�,.�t....,(�t. ... _ r.._,. � �.............................. ........................
� qz
,.
Stree
as shown on the application for Disposal Works Construction 'enit Na_ "Dated_._._¢ . _ °'
_ .
J . / Buard of Health e-,
DATE: �'� < .-/-- -------------
FORTH 1255 'HOBBS & WARREN. INC.. PUBLISHERS