HomeMy WebLinkAbout0009 HIRAMAR ROAD - Health 9 -�j �'avv,a,r tsacQ
No....7 3 Rq
Flc> .A.�...P.�...........
THE COMMONWEALIWMASSACHUSETTS
BOARD OF H!'ETH
_�/�. •_ Z+ _...----------OF...... ../.. .....-_�----------------------------------------
Appliration -for Riipnna1 Morks Tonotrur inn Vrrutft
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
w..!���..............
Location- Kss or Lot No.
O ner/' _ ,�+ Address '
I staller Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms------�- --------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type.of Building ------------------------_- No. of persons.---- - --- ............ Showers Cafeteria ( )
Ga Other fixtures -----------
- -------------------------------------------•-•-----------.......--------------------------------------
W Design Flow.......................................... gallons per person per day. Total daily flow--------------------------------------------gallons,
WSeptic Tank—Liquid capacity allons Length................ Width------..-.------ Diameter................ Depth_--------------
x Disposal Trench—No--------------------- Width-------------------- Total Length-------------------- Total leaching area.--_-----..--.-.-.sq. ft.
3 Seepage Pit No/0-4-A-------- Diameter.................... Depth below inlet......--....---..... Total leaching area----.-------------sq. ft.
Z Other Distribution box ( - ) Dosing tank ( )
Percolation Test Results Performed by------- ---------------••----------•--•---••----•-------. ••. Date........................................
Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.............------. Depth to ground water..-------.--.--.--.-----
(%, Test Pit No. 2................minutes per inch Depth of Test Pit---..........------. Depth to ground water--.--.---------..-------
O - =
Description of So' --- ----`'
U GL^
. .
-- ....... -- ---.----------------
UNature of Repairs or Alterations—Answer when applicable.-- ic.-/ .-:-4..... . ......-�s --------------
-------------------•----------•--.-...-----------------------------------------
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 t board of health.
gned- ` --------------------------------------------------- ^
Dat
Application Approved By-------- = ' .2
ae
Application Disapproved for the following reasons:...................•--•- ........
.... ......................
.............•-------------------------------------------------------------------------------------------••--••---•-------------•-•---------------•---- --- ------- ----------------------------------
I �Date
Permit No.. Issued.....--•-- ..........------
' ate
No.._ F>l ..........
.. _._._.. ..'` .......
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® F HE LTH
.%.
.r-.;,� oF....._ -.. .. .. ' '..:..1` ......................................
c
Applirtttinn -for 'tipuittl Works Totwt u ton Vermit
Application is hereby made for a Permit to Construct ( ) or Repair (' ) an Individual Sewage Disposal
System at:
v Location- Tess or Lot No..
r
Qner y Address
W s
9staller Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms------r '. .._.__-._•-_-••_-___•------_--_-Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ._---_--------------------- No. of persons.----�._-.�-____-____-_- Showers (.�) — Cafeteria ( )
a Other fixtures ____________________________'
d ------------------------- ------------ - ------------------------------------------------------------------------
W Design Flow-----------------------------------..........gallons per-person per day. Total daily flow............................................gallons.
WSeptic Tunk—Liquid capacity/:3�afl_gallons Length................ Width...............- Diameter................ Depth.-_.__--_.-----
x Disposal Trench—No- -------------------- Width-------------------- Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit Nol.Ctrr-�........ Diameter____________________ Depth below inlet-------------------- Total leaching area----..-.----------sq. it.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-------------------------------------------------------------------------- Date-----------------------------------.._..
a
a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water...-_-----_-.--._-..___.
(i Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water--.---_--__--__-__-_-._.
•-•------------------------------------------------------•-----------------------------••••--••-•••.........................................................
0 Description of Soil------------------------------------------------------------------------------------------------------------------------------------------------------ ----------------
x
--------------- --=-------------- -------------------=----------------------------------------------------- ------------- ------------------------------ =--------------------------
U Nature of Repairs or Alterations—Answer when applicable.-. ------------1�_ 4__ ------ ). ---------------
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 t e board of health.
Signed ° k
ad a rl e.
Da t
Application Approved BY--------------� -, � r'��� * "a'�
ff Dade
Application Disapproved for the following reasons___________________________________________ ___________________________________••--------- --
----------
-------------------------------------------------------------------------------------•--------------•---------------------------------------------------------------------------------=-----------------
Date
PermitNo......................................................... Issued...................--- ................................
Date
THE COMMONWEALTH OF MASSACHUSETTS '¢
/7.
BOARD OF') HEALTFT" �
Trrtif irttte of Tomplitturr
THIS S T E FY, That /the Individual Sewage Disposal System.,constructed ( ) or Repaired ( )
a„ i
f / Installer
at ---------- i�c�................ , t----. -----.
has been installed in accordance with the provisions t3 Article XI of The State Sanitary Code as desc dam' the
application for Disposal Works Construction Permit No------------------- _. '_. dated___. .
--- .......
THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARAN _
SYSTEM WIL19 FUIVCT19M SATISFACTORY.
✓I
DATE........... J --------------•-•---•----•--•-•• Inspector---------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
... . ... ..OF.: ........................................... .
FEE........................
tttttl i1r , rti�t err �
Permission is herebyrante -____
g d��`` fe ---- --------
Permission is)ioV Repair ( an I djvid - 1 S age Disposal S}�s"tem E AR` V.
----------------------------------
at No
ect
as shown on the application for Disposal Works Construction er it No
�� Board of Health
DATE....... ---------- --- -------=-�= ------•-----------------------•
FORM 1255 HOBBS'& WARREN. INC.. PUBLISHERS