HomeMy WebLinkAbout0015 FROST LANE - Health (2) � %rosy 1��
O I R i F>�� ...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALT
Appliration for 15ioVoottl Worko Tonstrurtion Vrrmit
Application is hereby made for a Permit to Construct (v) or Repair ( ) an. Individual Sewage Disposal
2�Sys s at•
�.... A - .- - . ..r-------------- --•---------- --SO -------- "--...: -
afro -Address or Lot
Owner Address
............................................
Installer Address
d Type of Buildings Size Lot--- 3 Z ---Sq. feet
Dwelling j No. of Bedrooms............................................Expansion Attic ( ) Garba.rge Grinder ( )
aOther—Type of Building ............................ No. of persons--____-_____-_____--__.-___- Showers ( ) — Cafeteria ( )
Q' Other fixtures _ --------------------------------------------------
W Design Flow..p..............��........•_�-gzllons per person per day. Total daily flow............. --_----------gallons.
WSeptic Tank-F Liquid capacity/. ".gallons Length.............•.. Width---------------- Diameter---------------- Depth----------------
Disposal Trench No..................... Width........... To n,,�� __._ ._ Total leachingarea....____.____:------s ft.
Seepage Pit No. 5---•••......••• Diameter// pthJ�tlilet Total leaching area_ _d_.�--sq. ft.
Z Other Distribution box ( ) Dosi tank ( )
aPercolation Test Results Performed by.......................................................................... Date----------------------------------------
Test Pit No. 1................minutes per inch Depth of Test Pit____.--.--.____-____ Depth to ground water------------------------
ti, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
P4 .............. ----------------------------------------------- --------------------------------------------------------
0 Description of Soil......................... •--••----------------------------------------------------------------------------------------------------
x
c,
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 XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ' ued b the board of he th
Signed.....• ---•••••. ......X •--•- - -- ---------•---------------
Application Approved BY %r" �f7`---------
Date
Application Disapproved for the following reasons:-------•----------------------------------------------------------------------------------------------------•••.
....-•--••••--•••-••••-•-••••-•••--••------•••---••••--•-••••-------••-•-•••--••••-•-••-••
Date
Permit No...............=......................................... Issued... -
D e
THE COMMONWEALTH OF MASSACHUSETTS
BOARD� F I--I-EA LT H
Applirtttion..for Moprioal i9orho Glatt" trurtion V.rfmit
Application is hereby made for a Permit to Construct O or Repair,(. ) an Individual Sewage Disposal
System at
sue" '�
..... 1
ati -Address , � or Lot r
Owner Address
w C .
. ,
---------------------------------------------------- .------------......----
� Installer Address
Type of Building—- „,, Size Lot=__�.;�_�;._:.+ __._Sq. feet_
C�
Dwelling o. of Bedrooms______________-��.___.___..._.__.____.._-__._Expansion Attic (. ) Garbage Grinder ( )
aOther—Type of Building .............................. No. of persons__.___._____.___..._..___._._ Showers J( ) — Cafe'teria (. .`)
Other fixtures-......................=-------- -
W Design Flow..................<<„_ :"= '� gallons per person per day. Total daily flow____._._____... - ':_..:..._....gallons.
WSeptic Tank 4 Liquid capac t/-- .___gallons Length---------------- Width.._._..... .... Diameter................ Depth_---:_- -----
x Disposal Trench—No._.______.__...._._._. Width__ :__.__ To 1 engt � g .Total leaching area.....................sq."ft.
Seepage Pit No____ _______________ Diameter,t_.;_ ,i pth° ie:_____ ___ Total leaching area _ __ sq. ft. : ~`.
�a . /a -
z Other Distribution box ( ) Dosi ` stank ( )
aPercolation Test Results Performed by-------------------------•-------------------•----------------.----•-••• _Date.....................................----
Test Pit No. 1................minutes per inch Depth. of Test, Pit.................... Depth to ground water.__-_-_.___________-----
4� Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water---------------------
Of, --------------------------•----------------
xDescription of Soil � ----•-------------------------------------
U -------------------------------------------------------------- . -•----••----•-••----------•-•---•---•-•------------------------------------ -----
------------
W --------- -- ------------------------------------------- -- ----------------------------------------------------------------- r
x CU Nature of Re _pairs 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 '
---
;�. �.l `"�-� � --•--• - ................................e
APPlication Approved.BY ...,� ' � '_ =.
Date
Application Disapproved for the following reasons-..........................=----•-----------------...------------------------------------------------------------
........................... ----------•-----------•----•----------••••-----------------=--------------------------------------------------------------- ------------------------- .....................
--. - - to
d
Permit No. --------------------------------------•.._..... Issued.. -•--- �. ---------
_ a
THE COMMONWEALTH OF MASSACHUSETTS
BOARD :OF HEALTH
. . ........OF.... . r ra„ ......................
wntif it tr 10 Toutplialta
THIS IS- Ty CERTIFY, hat the Indluuidual Sewage Di posal System constructed ( ). or Repaired ( - )
� ,
1" ' Install•;-s,"v y
has been installed in accordance ith the provisions of Article Y,�of The St,to Sai rtary Code as described in the
application for Disposal Works Construction Permit No.......... ed--_.7 _An'
THE.ISSUANCE,OF THIS CERTIFICATE SHALL NOT BE CONSYRU AS A GUARANTEE THAT THE
SYSTEM WILL FUNgTION SATISFACTORY
.. Inspector.......
DATE ---
. T •f �----�-.--g P ,�'-'--•--�?.�y:-: �, -t <.v�_ „�°
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/ 3 %&7,1....... OF............ '''�i°81�x' r� . ..................
.43iiiVrIottl Mgrk I !eo
Permission is hereby .granted- pY - - .---
= ..................................................
to Construct ( 4 ) or epair ( ) an Individual Sew ge' Disposal st
- e , r
' Street' / ,,,
as shown on the application for Disposal Works Const uction Permit No ... Dated,__..__ Dated-_,.- /' 41 ,-_-•.----
..............................
� oar¢ of Heath
DATE------... !-•-• _ 'l .
FORM 1255 HOBBS & WARREN-�INC.,,PUBLISHERS