HomeMy WebLinkAbout0033 GOOSE POINT ROAD - Health �3 68�� � �
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THE COMMONWEALTH OF MASSACHUSETTS
ARD PHEAL.
Applira#iun -fur Dii uiitt1 lVarkii Towi#rurtion Vrruift
ar Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
Syst at:
. -•••-- •-------- c --
ocation•Ad ess - •-- or Lot N
--••------•-- r d"� 2 - -----•---1
Owner Add esf s
. .......... .. ..........--------._............._...._.._._..........._._..........._
Installer Address
UType f Build• Size Lot_______________ -----------Sq. feet
a Dwelling No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
pi 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 ( )
aPercolation Test Results Performed by------------ ............................................................. Date--------------------------------- ------
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.................... Depth to ground water-...._.--______--___-_--
a -----------------------------------------•-----------•-----•-----•-•----------•------------•-••-------......................................................
0 Description of Soil............................................................................................. -------------- ----------------------------------- -----------------------
x
--------------------------------------- ---------------------------------------------------------------------------------4��
- - - --------- --
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...................................................................................... ................................
Date
Application Approved By-------------------------------= -• =';;��ram --•--•-•--•------:=�a
Date
Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------------------------
................•-•••---•••--•--------------------------••-•---------------------------------------------------------------------------------------------------------------------------- ..............
Date
PermitNo........................................................ Issued........................................................
Date
"0
No. .............. .............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAL
-----OF......% •' r- _:..
Appliratiott -for :41.4poottl Works Towitrurtiott Vrrmft
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at: 1
` -- ---
Location Address „, ✓, or Lot No
-- /-----------_�----• ................................................/tt ................ .►. /.._.h___. 'Q. ....�`.`"�^?...... _ ......
If Owner f Address ..._ ..._
A w
Installer Address
d Type of Build• g! Size Lot----------------------------Sq. feet
U Dwelling No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aq Other Type of Building ---________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures --•---------------------------------------------------
W Design Flow--------------------------------------------gallons per person per day. Total daily flow..------------------------------------------gallons.
P4 Septic Tank—Liquid capacity------------gallons Length---------------- Width..-_--.-__._.. Diameter_.__--..---_-._ Depth----------------
xDisposal 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---------------------------------------
,4 Test Pit No. 1----------------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...---------------------
9 ------------------- ------------------------------------------------------------------------------------•••-----•-•------...._......._..-•----•---•---.......
ODescription of Soil----------------------------------------------------------------------------------------------------------------------- -----------------------------------------------
x
U -----------------------------------------------------••-------••----••••------•-•-------------•--------------------•---•••-------------- --------------- -----------------------------------------
----------------------------------- ------------------------------------•--- -----------------•---------------------------- / ----------- ---
Nature of Repairs or Alterations—Answer when applicable.. _ /%_ ..-. _ �[t_�.-_ _.. .___..
------------------------------------------------------•------------------------- ........... ---------------------------------------------------------------------------------------------------
O!
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...................................................................................... -------------------------_---
Date
ApplicationApproved By-------------------------------------------------------------------------------------------------- ............ -----------------
Date
Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------------•--------•--
•--------•-------------------------------------------------------------••----------•-•--•----•-•--•-•••-•-•---------------------•.---------------------------------------------------------------------
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
1
......OF. ............ ......................................................................
0'rrtifirate of TompliFuue
T_R�S IS 710- CERTI,FY That the Individu KSewage. Disposal System constructed ( ) or Repaired ('
y
� r ? -Installer �
at i >. , - '; ------ t-- . --------------
has( en installed in accordan with the provisions of Article
dI of The State Sanitary Code as described in the
�r� ,.
application for Disposal Works Construction Permit No____________ __.__:>.._...___.._..__. dated-------a -------.. ...........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL Ff/N TION SATISFACTORY. —
DATE �� =f a�j ...................... Inspector------.. �-- ----. -- ------------- ---------------------_---_-------•--
THE COMMONWEALTH OF MASSACHUSETTS
a � BOARD OF ,HEALTH
i!• ,c.�7OFi .+.y:-:�.. ................................
N •-------•--••---
o. - �• - . FEE-----:._..-
Binpoiidl orki� CIToubtrurt/on Prrmit
Permission is hereby grante e = f---c.`r-!r"---.� �t ------------------------------------ .................
to Constructs( ) or Repair ( )fn Indivtdual/S"eage Dtsp.�isal --yste + i
:_--- -•----- --:• ---------
.I'r'� .i� '
as shown on the application for Disposal Works Construction Permit- o........ ----------- Dated_.. ':° i
-`-- '✓ mil,< -------
,--,
Board of'Hof
DATE. ' j ?----- .. .«.�------------- --------------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS