HomeMy WebLinkAbout0012 DORCAS DRIVE - Health 12 �✓e,_.s Llroi.�
LOCATION SEWAGE PERMIT NO..
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VILLAGE
INSTA LLER'S NAME & ADDRESS
B U I'L D E R. OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED ��7 �
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} THE COMMONWEALTH OF MAC+SACH.VSETTS
BOARD • F HE TH
..... _..-
Apli iratinn fur ]N!ipn iat Workii -Towitxnrtion Punift
Application is hereby"made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
r1 Location-Address or l�etC o
11
C�.. -N-=----•.:...�..� - �1..... .......................... �► ----• -------- ---------•-----•----....---•----
Owner — Ad jr s
WV`"2. ` l l`tG`------ � v�"5-----------------------------------------------
Installer Address
Type of Buildin �,_ Size Lot.... ... _ 5 feet
U YP - q
Dwellin —No. of Bedroo ___________________________________________Expansion Attic QV-0) Garbage Grinder ( )
Other—Type e of Build �`-�'vi_
p, yp g ` _ No. of persons...___,?.............. Showers (.Z..I ,— Cafeteria ( )
PaOther fixtures -----------------------------------------------------
W Design Flow___ _ ..........................gallons per person per day. Total dail ______L ----------_............gallons.
WSeptic Tank—Liquid capacitJ _gallons Length---------e.... Width.__-T-------- Diameter----._...___--_ Depth............._.
x Disposal Trench No ...................... W'dtli____ --- -_- . Total Length-------------------- Total leaching area......... ft.
Seepage Pit"No t:: { :Diametervl':______________ epth belo inlet_..............._... Total achin dreh. _-- ._. _____sq. it.
Z Other Distribution box ( .) Dosing tank ( ) d7` �/— a a - „f �
Percolation Test Results :, Performed bY--------- ------------------------------------------- .................... ,Date-------=--®----------------------------_
,aa Test Pit No. 1.........:......minutes per inch Depth of Test Pit-------------------- Depth to around water...---.---__-.-_-_..___.
Test Pit No. 2................minutes per inch Depth of Test Pit.--_--_---_._:__-__- Depth to ground water-..-----------------
a' i E
.......................
Description of Soil
x
U = ..
Z ---------------------------------- --------------...........................................................--------------------------------- ------------------------- ------------------=--------
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 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.
i - ....... - ----- ......................... --------------------------------
-
D
Application Approved BY ` A ad�`
Date
Application Disapproved for tlie.,following reasons_________________________ ........................................................
......................
••---•---•---•--••-•-•-----•-...•---•-=--•--......•-•------•--•--••------------------•---•-_.....--------•----•----•----•--------------------------------------•----------•------------•--------------=-
Date
PermitNo......................................................... Issued-------------...........................................
Date t
-- - ---- ----------- -"- - '-=----------------------------- ---- ---------------
No..... ".._/R.'a... FE$.....P.................
�1 Mt THE COMMONWEALTH OF MA$SACH-,,USETTS
• BOARD F H TH 1
OF
A'VitrFatiuu -fur Uiapviittl Works Tomitrurtiutt V trout
Application'.is hereby'made for a Permit to Construct ( - or Repair ( ) an Individual Sewage Disposal
System at
Location �1dd es sit
or "[V
rc,
j� wrier
fj _y� yy
Installer Address.,,
ddress,
Q Type of Buildin Size Lot.::_ _. .........Sq. feet
aDwellin -No. of Bedroom ._._ .t.- � g ( )U __..Expansio tttc Garba e Grinder
Other—Type of Buil.din 4 � ». No. of persons _........ Showers Cafeteria 0.1 YP g P ----- ( ( )
d Other_fixtures � -------------- -------------
.----
- W Design Flow____ .___-_ gallons per peison per�1ay. Total d1 _ ........................ .gallons.
Tutik—Liquid capacity gallons Length___:'_:--- ... Width.. �Dtlmeter----:........... Depth----------------
Septic
xDisposal Trench—No_ ____________________ Width-------------------- Total Length-------------------. Total leaching area.:.-----------------sq. ft..
Seepage Pit No........... :...... Diameter.................... Depth beloy inlet__________ ....... otal achii_i = fr t ___ :._..__sq. ft.
z Other Distribution box ( ) Dosing tank ( ) . oh- J
aPercolation Test Results Performed bY------- ---------------------------------------------------- Date---------------------------------------
Test Pit No. 1................minutes per inch Depth of, Pest Pit-------------------- Depth to ground .water„:._ __---__-_.._--_-._
fx, Test Pit No. 2._______________minupes per inch Depth of Test Pit._______---- --___ Depth to ground water_.___.:_:_:_____-
- r
D Description of Soil------------ .� ........................... ---------1?----±--
V -----------------------
W
V 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has ben issued by the board of health. ..
ign ................................
Application Approved BY--' I •--• . . �~4w 71
. ---------
Date
Application Disapproved for the following reasons:.................. ...... .....••-_=•... ..........._.______.._.__.._...____:__._...._.......____.__.........
.............................................. ---_-.------------•-••---•-•-----=---•----•-••--•-•-------------------••----•--------•---------------------•--•------------=•--------------------------
Date
Permit No. - Issued..........................................
_ Date
THE COMMONWEALTH OF MASSACHUSETTS `
BOARD OF HEALT
..........O F............W�...... ...: ....... 11..�'�^
OvIrrtifirute of f"uutphattrr
THI TO CER Y, That the Individual Sewage Disposal System constructed ( or Repaired ( )
by 's" "'
Installer
at. x
has been installed in accordance with the provisions of :1r ' l,V I of lie State Sanitary C41, as:descxi in the
application for Disposal Works Construction Permit No_______ _________J_ _41_............ dated....... .._..._..------------
--------------
THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM, MALL FUNCTION SATISFACTORY.
DATE------.. ` 7 7 Inspector .._.
-------------------------------------------•--•-----•----....._..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O/ HEALTHY
No. FEE...... ..........
Bi voli a! -kW TTuttr " rtiutt rrMit
Permission „ her ranted -------- ---------
to Constr ., or pal ( )..an Indivi u 1 Sewage sposal System
Street W
*M�r7
as shown on the application for Disposal Works Construction Per it o ___ ------- --------------------_..........
Board of Health
DATE :. -------
FORM 1255 HOBBS & WARREN. INC.: PUBLISHERS
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