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HomeMy WebLinkAboutUntitled _ y 1J�1 l✓ No.......... ..... ., Fss.............................. r � THE COMMONWEALTH OF MASSACHUSETTS oU� BOARD OF HEALTH ..----....--:..............................OF.......................................................................................... Appliratiun for 11iipusi al Works Tomitrurtiun Prrutit Application is hereby made for a Permit to Construct ( "or Repair ( ) an Individual Sewage Disposal System at: . Location-Address or Lot No. ,�;4y 9 W cJ r m S Installer Address ��// Type of Building Size Lot.-.T__ ,3�3..Sq. feet Dwelling—No. of Bedrooms......... ---------_._.................Expansion Attic ( ) Garbage Grinder ( ) — Cafeteria p., Other—Type of Building ............................ No. of persons........____......_..__.___. Showers ( ) Caf ( ) Q' Other fixtures -----------------------------••- diMW,Qeia�--------------------------------- ------------- WDesign Flow......1 _ ........................gallons per�ssnn.per day. Total daily flow............................. %.........gallons. (�----. allons Length....-6........ Width__... . Diameter................ De th.. . . Ra �Se�tic Tank—L' uid capacit�� --� g � �!.'...... p �_�._...__. Dfspo rench ....CO).... Width,l��............. Total Length..,F ..`..... Total leaching area.�l�z� sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( v4 Dosing tank ( ) ~" Percolation Test Results Performed by---410......... .n.5;. .................. Date....... /.., .:. ------- Test Pit No. I.r.<..---Z__._minutes per inch Depth of Test Pit---8a(-... Depth to ground at r.......7............. Test Pit No. 2..!55;..2....minutes per inch Depth of Test Pit...c .y.. Depth to ground water.....'-...`°..... a -- Description of So'1._..a.®. �.--- .......�c .. ;y ...' .. _ V Nature f epairs or Alterations Answe when applicable ---------------• r -------------------------------•---•----............---_------------------------------•--•-•--•-......-----...------------------------------. ----------------------------------------------- Agreement:' The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of 71LT i:E 5 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. InSig d ...-• ----------------- ------------------------••••...................... Date Application Approved BY ;•.... aZf DatXY-------------- t Application Disapproved for the following reasons:-------- -•---•------------------------------------------•-•..._... ................................................................_.........................:.............................................................................................................. Date Permit No................................................... .. Issued-----`.�'��•_2 z- . t , Date- �" No..........J`=.i Fus....: S ._ THE COMMONWEALTH OF MASSACHUSETTS i BOARD OF HEALTH �w p'd Ap lira#ion for Disposal Works Tnntrurtiun Vrrmit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at _. •-•...... ......... ...........•-•-- ................... ..................... ....-....... Location-Address or Lot No. ....... ••- - -----•-•--....• \ - -• 0t----------- -- ----••-- Addr a ..... .._. fo ^................................. '". Installer a Address Type of Building Size Lot... ._Sq. feet U ----- Dwelling No. of Bedrooms ---•--•--••-.. __ _Ex ansion Attic� g— ---.------- p ( )s Garbage Grinder ( ) Other—Type T e of Building No. of ersons____________________ Showers — � YP g --------•--•---•--...---•-•- P ----- -- ( )� Cafeteria ( ) Otherfixtures ------------------------------•-•-•--••-------- W Design Flow...... ..C:>......:.................gallons per-person.per day. Total daily flow.................. .........gallons. • r W Septa Tank `Ligmd ccaapacrty '�P_gallons Length._.r!___.._. Width_ �/ ._ Diameter________________ Depth_ 9.......... x Dls osa reach— . . ._. �e ____ Width./-"''_.____.___ Total Len th._ :� Total leaching area.�__� � s ft. P g g -•••--•-- q Seepage Pit No---------------------- Diameter..................... Depth below inlet............. Total leaching area.................. ft. Other Distribution box Dosing tank ( ) Percolation Test Results Performed by_ ........ ................... Date..... __ `....- Test Pit No. 1._f�` ._minutes per inch, Depth of Test Pit �`._ ___ Depth to ground water._.__._A' GX, Test Pit No. 2__ ..minutes per inch Depth of Test Pit.__ _ ...... Depth to ground water...... _ __"..... Cv' ••• _ '----n` Description of Soil - _.........................'�4. . '"`� = ` _ .. -- --- - ....... . ..... .. .. 4 x ! U Naturekm airs or Alterations Answer when applicable__._:__ __ . ,,, --•--•----------------------------------------•••••-......_-__-••-••-••• •••-•••-••-A• _•--- ,� --�••._.._...---........__. Agreement: The.undersigned agrees`,to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of"I E, A. i ,e 5 ot'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.. Sig d.:` ••••.._.._••_•__ ___. _E: ........ ........................... ___ ._ Date Application Approved B --••- _4/'-7Q------------- PP PP Y _ Ill *r Date Application Disapproved for the following reasons------- =------- •- .................................. ............................................................................... Date Permit No.................. Issued_..................................IZ7' - .. Date THE"COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r < i ........OF..... .... ! ....................................... Trrtifirtt r of Tu t rtt�anrr Y •t THI IS TO`C TIFY, ha 'the Individual . e D s oral stem co t ct • e aired ( ) by ......... ....................... ._ In ler has been installe yin accordance with the provisions of T j f The State Sanitary Code.as described in the applicatori.for Disposal Works Construction Permit-No.__ _ :+ ____.____. dated_._. _`A_ ``_.j` _ THE''ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORYs11 ` DATE................................................................................. Inspector................................................Raw, $ ' , J t, THE COMMONWEALTH OF MASSACHUSETTS BOARD OP HEALTH , .............! ��'''.'�j.....:.OF........... _._..._ r N ........... FEE....-- ........ r ,., i ern 1torkis a U141 ion i# .. Permission ip hereby granted 9.... .r • ••••••••• •-• •••••• .... ... . to Construct t ' o Repa ( ).a Individu Sep a e is p al S3� tem I ,f at No... .° .f.. iL'�! *", sr"' bw_............................................................... Street { as shown on the application for Disposal Works Construction Pe o. .. 'ateed..._]�__.l _!�z*.. •---- ••-• ... / Board of Health t % DATE•- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERSI --.1.+:.: ,. .., -. .. . .'ww�Ifi.... :_.,a::3r sn+. .w'-k,s+-; ... ., -.Iw+.wsw+±.-^-.y.+�e:+ orv.1.-.,.,1,�:r*�+.r►«:..-„w.., -...,........ .....»...,,:yr,w,.__.-_. -.r,w,...•,+r-.-,.,,+•..-_w. ....--.-..w.r.+«..+...mflrrr -._..._-____. y-fib ,.. '.. «_•'-..-. ...a,•. .. .. .. - E : pi<fv3 Z �g7% — -_ • j � t aes% EZjE"Y. ._.. flCXr3�ir�e� s�7rauno/ Profi/e L.+ Q /p' -- - ____-_-.� o a--o--- pro�dsed ground prod'„e -- F L O ZA/ T- .SCHG�l3. 40 i?t/G. O E' Is7�r7rrnurn %.. per foot + v/s7- E3 o7.1�-]7�� X --• y' j- 6" G p f /000 �i9L. $ EPT1C T/git1� 3�y -11 y �/ i :3 Gv ?ram' - - -4 �= 1 p S / G �.J -__ -- 7-6- S 7- f-� U G. E-- 4L 0 6 c3 E o:�o o r� o s� a.9 T EST BY -- .ti L v/ 7-,A/E S S 1 i L/C--- 1117 U lele 9 Y, Q E 7! ._- 1 30 G!9 u M•S-C.. '_` G-;e2rn5�at�/� Bd of New, /f L S.�L�AY OA TM /7 i \ 9 7-E57- Hac # i 77E57- H©L- E 5 - � GloqL. 7-,,9^J,4e w P/ = 8.2 4Z /Oa177 24 B/ /ecz n \ C /ea/7 .41 ci.•vc°' sand .O �✓� .? O< GciASHFO 37Zs•.iE l rnec�.'um me:� nr;u 9 3 10.0 Sa no/ D � ato � 1 � v• � / G E�E'T/FY THAT THE BU/LO/�/G r r� __ -- p/eOF'OSEC; pN THE_- G�OUNO AS 51 T�G S �OA 6-7 � � oq AJ SHOWN Oil./ TH/S F'G.RN Lit//LL _ _T__ �4 L.. 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