HomeMy WebLinkAbout0048 IYANNOUGH ROAD/RTE 28 - Health NQ.......... FIzic..............................
• �+ � THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......... -. .. ...............OF.................................... ........-------._..........---..............-----
Applirtttion -for Uhipoottl Workii Tomitrttrti -prrtitit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: � —
L.07 /� -� '//9'V G GiG N �Cl/ 7 S�
---•----•--••-------•----------•-----------•----•-•-•-------•------------------------------------- ---------------------•---••-----•-----------••------
Location-Address or Lot vo.
.�_!✓/_'. ..�...........^� °N ...................... --------------------------------..............----•------•--•---•----............................
Owner t Address
------------------ ----------• ---• .....................................
Installer ��rl Address
UType of Building k/U �" Size Lot_..��_---�-----___Sq. feet
Dwelling—No. of Bedrooms----------------------------------_---------Expansion Attic ( ) Garbage Grinder ( )
per, Other—Type of Building ........ No. of persons........ ................. Showers ( ) — Cafeteria ( )
Otherfixtures ------------=5-----�---•--------•----------------------------------------•------..---------------------------------------------------------------
W Design Flow........./.S.................._....._...gallons per person per day. Total daily flow.................___.:..__.________...._._..gallons.
WSeptic Tcuik—Liquid capaci?v'7.!?f?-gallons Length---------------- Width-----........... Diameter------.--------- D_epth---_-_-.-_---
x Disposal Trench—No.------1_____...... Width------ Total Length_.__-_) U._.. Total leaching area...5._c'c)_...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....-----------......-----------------
,� Test Pit No. L---------------minutes per inch Depth of Test Pit-------------------- Depth to ground water...---_-.-----.--.----.
rZ4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water_..-_.-____-___.____----
a ........................................................c --------------------------------•------------------------------------•-----------------------
Ox Description of Soil----- ...._Ai1•9/ --- 'AIX7l " G� - ---- ------ !-----
------ ----iry- ----- -----.-. �
U
UW •---------------------------------------•--• ---------------------------------------------•--•---•-•------------------ --------•---------------------------- :----------•_---.------
Nature of Repairs or Alterations—Answer when applicable.._-�. .X.____ �d..�_.____Gj.!`).C_'"'A -- ! �
---------------- `f` 'r -rf.,y H-........--••--------.
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 ;�!t _� try</�......... Ui / — / S`'
-------- ----- ---
---
/C Date
ApplicationApproved By-------- ---------•--------•----------------------------------------------------------------
Date
Application Disapproved for the following reasons---------------------------------------------------------------------------------------------•-•-------•-•-------
-----------------•------------------------------------------------.------•-------------•---•--------•----•----------------••---------•--------------------.----------------------------••---------------
Date
Permit No------- .........................................................7
Issued
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF............I�AX...41T�r��/_
Qprrtifirtttr of f�ontpltttttrr
THIS IS TO CERTIFY,jhat the Individual Sewage Disposal System constructed (-.) or Repaired ( )
by................. ----------C.r,
1 Instal"
at................ ..........�----------1=�-----------� ��'�� v f-L"fw .
---•---------------•------._......----------------------.............------------
has been installed in'accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No------- -- ------------------------- dated........ ...r.... f/ram .rA_:_...7,1
f
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTOOR/R''Y.
DATE ---- -- --�- .......... -1�--- Inspector-------�------------ --- ------------------------------------------•-------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
0/lL.........OF............�.�.`i..`.-S....�............................................ Off✓
No. �_ .... FEE- ...2 // ........
�i��o>�ttl ork� �on�trttrtiott �rrotit .
Permission is hereby granted.......... h
to at Construct (�) or Repair ( I/)`an Individual Se age Disposal System
�� �s
/) Street
as shown on the application for Disposal Works Construction Permit No
----- Dated------------------------------------------
__-------.
Bard of Health l
DATE.........
--•---�=�=--��- ----�l'�........
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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5771
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