HomeMy WebLinkAbout3780 MAIN ST./RTE 6A(BARN.) - Health LOs, ATION . SEWAGE PERMIT NO.
6 A 0 C3If N,374,6 cf— s - q a j
VILLAGE
I N S T A LLER'S NAME A ADDRESS
B U I L D E R OR OWN ER ry
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
'OVAO lkxin (o 14,
7
THE COMMONWEALTH.OF MASSACHUSETTS'
BOAR® OF HEALTH
° ..OF...... �•-.... .............. f
ApplirFation for BispoiiFal Works Tumitrnrtinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair (11") an 'Individual Sewage Disposal
System at:
......&.? ____ ...... .._:...
_ ----.--•......:......................................................••..... --............._
Location-Address or Lot No.
_�!�if✓!V ......................................... .................•---•-------... •--- --....------. .............................
Address
14 �%..
Installer ,Address
Type of Building Size Lot............................Sq. feet
Dwelling o. of Bedrooms............................................Expansion Attic ( ) , Garbage Grinder ( )
'q Other—T e of Building _.... No. of persons........................... Showers a YP g --------•---='=--••--,- P - ( ) — Cafeteria ( ) -
Other fixtures . -= ............................................ ,
W Design Flow.........................r..................gallons per person per day. Total/daily flow............................................gallons.
xSeptic Tank—Liquid ca akit ............gallons Length...............- Width................ Diameter.--------------- Depth................Disposal Trench—No._._:.1............. 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........................
fro Test Pit No. 2................minutes�Jr
inch Depth of Test Pit.................... Depth to ground water...................
Q,'0 Description of Soil -----------------•---------•--•---•-......•----•......--•-•••--
V ............•--•••••-----•--•--•----------•-----------------------------------------------------------•---------••-•--•-----••••-- ---- -
W -•.•-•-•-------------------------•• .••••..._.....•--_• ........ �.
U Nature of e airs or It ratio —Answer whplicable_....:'e__. � ..__ ___.d . ,� - __ 7� ��/
j
d !`.................. ------14U � ..----•-----`.-............ .......................... -----------------------------------------------------............----
Agreerlent: f
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITL M 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ssued by t b d of ealth.
��
Signed., � tr=•--- .......�.
••-
Application Approved B Date
Date
Application Disapproved for the f owing reasons:---
................••--•---•----••-•------•---•-.......•••••--•--................................----•-•---.....-•••-•--••----••••••••-•-•••-•---•--..............................--... ......---•--
Data
PermitNo....................................................... Issued.............................-.........................
Date
�l9
'Cl p
1
I �
�o
No......................... Fuis L fJ
THE COMMONWEALTH OF MASSACHUSETTS
.., BOARD OF HEALTH
...OF....../ I &
dw
Appliration fur::`- iivusa1 Workii TumUurtiun Vamit
Application is hereby made for a Permit to Construct ( ) or Repair (e an Individual Sewage Disposal
System at:
......� 70 ...... 1 ___ _ __
Wocation-Address or Lot No. - - - --•"
_— - " - .................... ...............................................
'
' Ow�.r .w.� Address
0/!/: ll all i� _.__._.!5�✓. r!....... __..---•-Add
......... .... ..
Inster ress
UType of Building Size Lot............................Sq. feet
Dwelling o. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building _____________ No. of ersons._.___________________._.___ Showers QI Other—Type g --------------- P ( ) Cafeteria ( )
_ Other-fixtures __
--••--------••------------•----••---'•----•-•-•--'-•--•----------------------•----...._..--••--
W 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........................................
14 Test Pit No. 1................minutes per inch Depth of Test Pit--------------------
Depth to ground water........................
44 Test Pit No. 2................minutes p inch Depth of Test Pit.................... Depth to ground water.........._.............
t� ---•----- --------------•-----------------•----------...---------............_..................................................................
ODescription of Soil............ :-------------=-------------•------------------------------------------------------------•-----------------------•-••------........------
x
x ______________________________________________________________________________________________________________________ . .- ��:::::::::_::
U Nature of pairs or Alt9rat>pn,�j'�A s er whe ` plicable__.____�':_:__ A. ___ ____
--'.h-1 __ -------------- ............ ................................................--'-••-•----•••---------------......................................................
.
Agreen ent:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT112- 5 of the State Sanitary Code— The undersigned,further agrees not to place,the system in
operation until a Certificate of Compliance has been 'ssued by it , bo d of ealth.
Signed. - ...... --- --- -- --- -'-------• -- �".... -----
Da e
Application Approved By------ --- - -- .. ----•••--- --- .......................-----
Date
Application Disapproved for the f owing reasons_...................
..........__..................................................................................
--------------------------•------------•---•------••-----•------
Date
------------•-••---•-•----- r'` _ Issued
Permit No............... ....................................................
Date
f � i
THE COMMONWEALTH OF MASSACHUSETTS ? ++
BOARD OF HEALT
.OF....... r . ._._.....
Trr#if iratr of (Inutpliatta
"S (� ERTIF at the Ind. ual Se Disposal System constructed ( ) or Repaired
�r`'
y (��(//(yy�jj�((//
tr st er
0
at...................-----•--•... `-•----------.._....._..--- ........................ __ �� --------•-•-
has been installed in accordari e,'with the provisions of TI T IZ 5 of The State Sanitary Code as descr'bed in the y
-
application for Disposal Works Construction Permit No.__ s__..Q z ______________ dated-------- __.___.,J�.............. t
THE ISSUANCE OF THIS CERTIFICATE SI-�ALL.NOT BE CONSTRUED AS A GUARANTEE THAT THE
'SYSTEM WILL FUNCTION SATISFACTORY:
11 - Q5
DATE........ .... ........ •----_... .........---------•--...--•••••-_._. Inspector--_..._ _'--••
1
t` THE COMMONWEALTH OF MASSACHUSETTS
-�-� BOARD 9F HEALT
.......................................� ....oF............. � ' ✓
, �' .,
d
FEE. �
i o� ko ,utrttrtio err
lPermission is hereby granted--------------'- -- oo111
to Construct (' or Re (+ an In al Sew Disposal t
Street
as shown on the application for Disposal Works Construction Permit No'��. �__ Dated_______ '__!
PP P 1J/�/.�..... f ..
DATE.---- -1-7- -------------------- •;}
- . .
FORM I'Z55. HOBBS&_WARR'EN:7 INC.. PUBLISHERS