HomeMy WebLinkAbout0088 CAP'N JAC'S ROAD - Health _.
THE COMMONWEALTH OF 1w,ASS,(HUSETTS
BOARDgF HEALTH
� �.^....... OF......... ..C �
Appliratinn for Uispmal Works Tonatrurtiun rautit
Application is hereby made for a Permit to Construct (/ or Repair ( ) an Individual Sewage Disposal
System at ` , -
............ .................V..'a...V.........
`` � 11 5�
Location-Address K or Loth No.
....... ..Cam...M................................... ............ - ' ^-o--?C..S/1/� .......
.-.-.....................
.
Address
� ......................................................
Installer Address
Type of Building Size Lot.Vs'3.a_.a......Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder A �
aOther—Type of Building ............................ No. of persons............_.........._.... Showers ( ) — Cafeteria ( )
dOther fixtures ......................'..................
W Design Flow..............VV0.......................gallons per person per day. Total daily flow-------------_3 _ ................gallons.
WSeptic Tank—Liquid capacitAP d'•'.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 nk (
Percolation Test Results Performed by...... 4 .................. ......... . ..._.. Date..... .......
1
0-� Test Pit No. 1................minutes per inch Depth of Test Pit..................._ Depth to ground water........................
44 4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 --............................................'.............................................( ---------------------------------------------------------
•-"-
0 Description of Soil---•'•..0.'•----?_...... 1 .... m•"•'-...'-'--"'- 'b-� �� }----------------------•----•---- ................0
x
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 iI'i U 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
board of health.
.
to
Application Approved By'--•-••--VI 'ng
- --•••-'-•'-'•........-'•-'-"--......-'__•- - -y.......--'-
._......--•'-------------- Date
Application Disapproved for the reasons--------------••----------•------------•---------•---•--------------------------------------•--•-••""'--------
•-•-----•--------•--------•----•-------------•-•-- .............................................-..........
Date
PermitNo......................................................... Issued-.......................................................
Date
t
No..... ... .. � F1ms..............................
THE COMMONWEALTH OF MASS4;(,-HUSETTS
_ BOAR® �F HEALTH
.................OF........`..........
App iration for 14opuoal Works Tonstrurtiun antit
Application is hereby made for a Permit to Construct 'E'er ) or Repair ( ) an Individual Sewage Disposal
System at
........ __......_....-y -.... -
Locatio -Address or Lo No
\ M �, .. -� c- ...................................................
' : • ner Address
W V_P . f\(t.... ....1� ................................
Installer Address
UType of Building Size Lot s 0._"_..`..--....Sq. feet
Dwelling—No. of Bedrooms.........'...: ................./......Expansion Attic ) Garbage Grinder
Other—Type of Building `� yp g ............................ Na �of persons_.::' _�_.___...._._-_..... Showers ( ) — Cafeteria
Other fixtures -------------
------------------------------------------
W Design Flow............1�.O._...•..................gallons per person per day. Total daily flow....... 3- ............._...gallons.
WSeptic Tank—Liquid capacit*!2 `'..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 ( ) Dosingtnk ( 4.._
~' Percolation Test Results Performed b . « ............r ...___..l`�_ ....... Date...._..................................�
a y.. _=
Test Pit No. I................minutes per inch Depth of Test Pit...._-_-........-`. Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
94 -----------------•-•••••••.................. ....-f.......
........
*----------------
----------------------
----------
D Description of Soil......-T*�..=..... c`(...................................................'
x ------------------------ ...... ` ----- --- «�U�' _........7�.. f tr --�..,.�
W
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 TITI14 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.
Si
Application Approved By.........
`
Date
Application Disapproved for the oll ing reasons---------------------------------------------------------------------------------------------------------------_
---------------------------------•-------.....------•--------------------....--------•------------------------•-•----....--------•-----•-•-•-------••--------••••--------•---•-----••-•------••----•---
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
.......
BOARD OF HEALTH
\...J `.r n
OF.....................................................................................
�rrtifirate of Toutphat r
TIII$$ IS TO CERTIFY hat the Individual Sewage Disposal System constructed ( 4-Y *o*r Repaired ( )
by.......... -----•.... .. ..•---------------....................................................
Installer
at............. .............................. �^ L�
�C \ C — �- � c�
has been installed in accordance with the provisions of T � r p.fLhe State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated--------------------------_.....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................... .... Inspector A?
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............0 F.........�•c..... `............................................................ r�1
No�..................... FEE.. .... ...
R.opoott1 Workii Tono#rudiott rrutit
Permission is hereby granted e ................................................................................................................
to Construct (L.-Kor,Repair ( ) an Individual Sewage Disposal Syst
at No........ : k-•-••-...A--�-------------- -Cr �..._.. ..`-:.L.A ~ n
Street
as shown on the application for Disposal Works Construction Permit No,....:..... ated..........................................
i __
DATE................................................................................ Board of Health
FORM 1255 A. M. SULKIN, INC., BOSTON
5+�1GLr-- FAM Q 0 0 :� �j•
IJD GA2B.AG[L G2,�.►bEc2 �� l
plat_.{ FLOW = IIU x 3 = 7306.Po
:jEPT1G TA►-,K = 330x15C> -A95G.P. o
Usti✓ l000 GAL. i j (/ � rl.° '.:
Dt5Po5A� PI-r v5E IvoD 6AL!�'I,,�+, ( h
o a? o..
I Z oT A L fl 1~S I G N = .4 2 5 G.P. D. ► FAAb N
Tc'TAL TDAILY FL-oW = -3 6Pc? I 33t , �\d
PEtZCOLATIOIJ RATE 11''IN 2MIN ot`LG55 ��
I / / i(
A18A
� ' IS2• I �
PLS N OF M.ps
Dc yG
o THULIN
r, c> No. 29976Ck
0 u i
A
e \ p �, STE4
A r l O,rF
C1515 �J. 4 ./�• TONAL
AID
ski
TE`�T /'*G Illo Top FNL) = I2o•3
FG= 11 1Nv. - 114
i 7 n � , y — �;•Loov INS.
1,�,r•vn
5 , , DUST. INJ. GAL, /13.P��
` CPT
ov Io Bu�c 1131E , rAN 1,4
2 I N�, j
U-3 l\
LE.ACL1
PIT INV. INS.
113.`L 113•c�
u/ITu r
-
�j,�.j.. / VIA S+d G D
� SToNE
GJ,n1)(.4L
10-7
i CE2TtFlCD PLoT PL-A1J
I° PRO F I L�
t.lo SCALE AT
-
's '
P L A r a RE EtZEN C'E I
i I
� CC`�T��V 't'4�t�-T 'T41E �bl�uT7(�TID� 51.10 tirt�N _ � I
A44= ZL&Qv+R.EMENT'> of �N�
o 3 p.. . �ti,�,r/����.<3 A N� t
t_OCA.TE� WITlt11.1 TN6 G1 DbD PLA11�1
DATEGl" I i '�,� G c}- ti BAXTEQ C W` E: INC. .
REGIS�S--Z& t-AuoSu9�YE`��1�5
Tuts QLn crr gt�Sr_r' old AN cv3'rtc2•vlt_t.E-
1u5 uPA W SV2V IC-y Fr -T 1=55ET5 '5W0UL3)
AIOTP_,E- t1"jEDTC� 17E7EFZ/^11.1E L.oT +-INE�j A PLICA►�T
--. ....