HomeMy WebLinkAbout0105 CINDY LANE - Health 1 oS C,rid
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® O HEALTH
�Ir�'�2.-.......OF............. %
,� lir�ation or Dig mal Works Tamitrurtinn Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at . j/ ...�-----
�,/ s'/^ Loc 'on- ddress .......--- or Lot No.
........I......... r+tfi' ..c. .... . ...- ..�.c��� ...................................................
7 er Address
Installer Address
d^ Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( )
Other—Type T e of Building ............................ No. of ersons_......._._._._...__.______. Showers —p., yp g p ( ) Cafeteria ( )
PaOther fixtures .......................... ...............................................................
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 ( )
Percolation Test Results Performed by...................................................................•-•--• Date........................................
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---------------.........
---•--------------------------------- -------------------------------------------------------•---•-•.........................................................
ODescription of Soil......................................................................................----------------------------------------------------------------••-•-•-••••..._..
x
W ----- ----
U Nature of Repairs or A erations— wer w n ap licable�_ __-n.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'TTL y g g p . y
of the State Sanitary Code— The undersigned further agrees not to lace the system in
operation until a Certificate of Compliance has been issued by he board of liea
®;f j
igned. ----'�-- � ---- '�7 ��1� "1----
----
�j, Dae - "
Application Approved By.........- C� VVV --
.......... .. ..... ---••-•--••-.
Date
Application Disapproved for the following reasons----------------------•••-•-•---•------ •---•-...•-••-•----•-------•----•----••---•--.........................
-----•............................•-------------------------••-----------•--------•--•--•---•••------•---
------------------
Date
PermitNo......................................................... Issued.......................................................
Date
_ I
No.._.�:./�/ . .. Fss.......11....._...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD Of HEALTH
f' .........O F..................... ....t.
Applira#ion for Oi-qVn.4a1 VorLi Tonoirurtinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: /
all 2-�- ;, --------------- ---------•- -......_.... --- .._........-•---••---------------
/ .Locati;.;Address or Lot No.
�..� Address
f Installer Address
QType of Building Size Lot............................Sq. feet
V Dwelling—No'. of Bedrooms................................ _Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
p' Other fixtures ................................. .
W Design Flow............................................gallons per person per day. Total daily flow.......................•....................gallons.
WSeptic Tank—Liquid'capacity._......____gallons Length................ Width................ Diameter................ Depth................
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 ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I----------------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........................
a ...................................... ----.._....----•-------------......------•---•-•••--•-••••-•-.........................................................
0 Description of Soil........................................................................................................................................................................
U ---•---•-••------•--••----•--•---------•-------------------------•---------•----•---•-------•••--•------•----•--•-------••-•;-------•---•--_--------------------------I----------•----••----...............................
............... -----------------------•-----------•-------.....--•-•----•-•--.._....................-------- ..................................... ---_ s-
U Nature of Repairs or Alterations— wer when
ell
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iT T L E y g g p . y
of the State Sanitary Code—The undersigned further agrees not to lace the system in
operation until a Certificate of Compliance has been issued by the board f healtth4
-gned_ r.:.�...�,r-�.. ���'i ./1 `���a, ��
._
' Date
Application Approved By. `' '= ...� '' ..................... 4' .........................
d
/
Date
Application Disapproved for the following reasons:._.. ----------------------------------------------•--•---------•----••-
----------------•-----------•----•-••----.....---•••------------•--------••-•---••-••...-•--•-------•-•••
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............� ... ....OF.......... ...............................................
//.Trrtifirat e, ,nf Trrntpjianre
THIS I C �IFY TT Tifiat the Individual Sewage Disposal System constructed , ) or Repaired
by.... ....._.. 1. ......................... ................_....11._._........._..._........._
at ._. ..Z.>!:=�1.I... 1..... Sto, ------------------------- .
has bees installed in accordance with the:prow s ons of 'I1 j of The State San y Code as descri din the
application for Disposal Works Construction Permit No.__ ____f -5_` -_.__... da.ted_....+ `....__....""
r- y _______________
y
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEtd#WILL FUNCTION SATISFACTORY.
DATE.........:::...............•---.............._......•--•....-----•--.......--_. Inspector........................._..........................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
LP �o
.' S— .....C�`r!i' '`�...OF.---........ '`!�' .-.........................................
No.---•--•-•-•�.-•...... FEE....''�..............
Disposal � .�Itltyl'j
Permission is hereby grante � ...
r�n
••.to Const?}ct � ) of Repa* ( In ividual Sege Dis os Systemat No....L---!---.L:- --------1� '-- '-'- � .....-- . - l
Street �_`as shown on the application for Disposal �Jorks Construction MertNo.. _'_�+..-�1_. Dated-,________ ..�.....�.......-.�. /.......
.a
`� 3/ �/ Board of Health f
DATE------.;- -- VVV""" C/
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS r'
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� •<...."/�..°tin.