HomeMy WebLinkAbout0006 GENERAL PATTON DRIVE - Health (2) Cane ecs0onS�i u
r;
No.-.4 ...... �R01__ 0'� Fims
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® Off HEALTH
.....oF..........10 .....................
Appfi.ratiun for Disposal Works Tonefrurtinn Vrrmft
Application is hereby made for a Permit to Construct ( ) or Rep 'r ( ),-an,Individual Sewage Disposal
System at:
..... .. ...... ..... ..... ....•.... . ......... .... ........... ...........
... . ... ... .... ..... . .. ... ..... ........... ....... ..
cation--Addre s ® ..or Lot No. .
... ......... ......
.................. Ad..... ........................................
. ner
Installer Address
UType of Building Size Lot..... .......Sq. feet
.� Dwelling No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
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..................... 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 ( )
'~ Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Dep of Test Pit.................... Depth to ground water........................
. �...........................................................................................................
ODescription of Soil-•---------------------------�...�....._'/---------...---...------...------.....................................................................................
V ....••-------------------------------------•------.....---...._..............--•-••----•-------....--•-•---------•••----•--...••-•-----••-----•-•------•---•-•••--••••--•-•----•----------••-•••.........
W
.......- - -----------
U Nature of Repairs or Alterations—Answer when applicable.,_.__ .. .....�� --__ _ _ ..
Agreement:
The undersigned agrees to install the afored cri d Individual Se g Disposal System in accordance with
the provisions of Article NI of the State Sanitary °ode The undersigne ther a rees not to place the system in
operation until a Certificate of Compliance has been N �ued by the rdPof lth.
Sig . . ------- ---------------------------------•------------- ...... .. ................................
Application Approved By.... Date
------ ..... /Za--'----------
Date
Application Disapproved for tlae following reca ons:.......................•-. . ------••-----•-•---•--------------•--------•...-•-•-----•--------------•---_.....
-•-----------------------------------------------------------------•-
Date
Permit No......................................................... Issued.--------------• _
,_._. -
........... ----- —------ -- --------------- I
-At- • s
No... . ------ Fici... ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEAL-rH
OF........... . .... . .
Apphrativu for lRinpasaf Workn Toutitrurtion Vamit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at* y
...... '._...- ~-Q .. .. � ......•----.... .................
I cation-Addr�z:� — or Lot No. '
.. .................. .......... .......••••.........................
er Ad ess
.... ........ nstalle�....`.......................... ........... Address. ......................
UType of Building Size Lot............................Sq. feet
t , Dwelling o. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther-Type of Building __________________________ No. of persons............................ Showers ( ) -- Cafeteria ( )
Q' Other fixtures .
W Design Flow________________________ gallons per person per day. Total daily flow_..._.__._._._._......___.._...-..__._..-_...gallons.
Wx Septic Talk—Liquid capacity............gallons Length................ Width................ Diameter•______________ Depth
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 ( )
Percolation Test Results Performed bv.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water--------................
f� Test Pit No. 2................minutes per inch Dep of Test Pit.................... Depth to ground water:___________.__.---_-__.
:1 ........... . ..........................-........................•--••••-•--....-•••••••••••----.......-••--..........----
Descriptionof Soil----••--•-•-•..... ' ""�_ ----------------------------------------•----------.--------------------------------- --------------------
v •••-••-----•---•-•••---,......--••-• =-••--••-••-••••••--•••-•-••••-•••-•-------••--••••••-••••---•-------••-•-••--•---•••••----•••-•-------•---•-••••••-=••-••-•---------•--•-•••-•-•-•----•-••---•...
W ----------------------------------------------- ...................................................... ........ p ------------- --- ------ ---
VNature of Repairs or Alterations—Answer when applicable-.._. ram,.. _
---------- ------- -••------------•--•---•-----•------•--....................
Agreement:
The undersigned agrees to install the aforedescrib'ed Individual Sei �'ge.Disposal System in accordance with
the provisions of Article XI of the State Sanitary CRde L The undersigne4�f ther agrees not to place the system in
P
operation until a Certificate of Compliance has been i� ued by the o�rd Wh"ealth.
Signed j,. '�-- ....... ..... i, ................................
Date
Application Approved By........ -- ------------------ a a...............
Date
Application Disapproved for the following reas ns:.................._.__.___. , ...............................
•------•------------------------•--------------------•--•••••••--•....... --------••-------------....._...------.........------------------......-------------------------------------...............
Date
PermitNo.......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
VG/ ..............OF... :. ..........
T S ISpr0,1ZERTIF hat the Individual Sewage Disposal System constructed ( ) or Repaired
by.:•• -•--. •..... .....-••_...- /Sta
-•........................................................
t all r
at.--••• am+ �° (_... - F.. "` ?----•---
has been installed in accordance with the provisions of Article XI of The Sanitary Code 1escribed in the
application for.Disposal,Works Construction Permit No....... ...............4.Z -_- dated.._ j1 ___.7,2 ..................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................•----......--------•---....-•----........:......-- ............. Inspector............ ----------•.............................................................
k
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r ...... 'j...........O F....... ................. t.+' ��..•"
No......�/_-_
,
Permission is hereby grante -• f' ........... . -- � •-• ---•••••
to .Constr ct ( ' ), r Repair dividu.al5 e age Disposal System
'
at No.. ._... .. ....... ...............
..
Street
as shown on the application for,Disposal Works Cori:;trdction P li No._ _:_ Dated__ _. ..............{�� �/..
-• •. ... -• ..................
Board f Health
DATE..-/ .. . �--------------- -----------•
FORM 1255 kos WARREN. INC.. PUBLISHERS