HomeMy WebLinkAbout4260 MAIN ST./RTE 6A(BARN.) - Health �/� �� � � - � G �
��� _o/G.
i
W rME falE {
I
i
i
i
i
i
I
i
i
0®® s M E AD]'
KEEPING YOU ORGANIZED
No.10334
B-153L
MADE W USA
GET®RGMLZED AT SMEAMON
�'Il
No(9' ,3 a,--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ZO HEALTH
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
Owner Address
Installer Address
Other Distribution box ( ) Dosing tank ( )
..........j...... ---------------
U Nature of gepairs or AT C.�ions—Answer hen a lica' :0�0 C/—. -----------------
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 issue )b t,e bo o f h eyft h.
Date
Application Approved By-------
Date
_7----------------------------
Date
Date
__________�_______ __
No......................... ..................
THE COMMONWEALTH OF MASSACHUSETTS
A ,^BOARD 0?5 HEALTH
OF......... G ' ...... ...................................... s
Application -fear 43Wposttf Works Tonstrnrtinn Vane t F'
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at
------------------------ -••--------------------------------------------•-•----••-----------
Loc ion-Ad s or Lot No
�--- U A. Owner Address
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms.............................. .............Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
0.4 Other fixtures __________________________________
W Design Flow............................................gallons per person per day. Total daily flow...........................................gallons.
04 W Septic Tank—Liquid capacity_���__gallons Length................ Width................ Diameter___._...-..---__ Depth.---------------
x Disposal Trench—No. .................... Width..._...._. ...((}.---
Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No........ ......... Diameter....k epth below inlet-------------------- Total leaching area........_......_._sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed bY-------------------------------------------------------------------------- Date---------------------------------------
a Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water-------.----------------
t= Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water___.-.._...__-___--__.
P4 ---------------- ----------------------------------------------------•----•----•----------------------------------•--•-•----------••-------- ------
ODescription of Soil------------tf�--------------------------------------•------------------------------------------------------------------------------------------------------
x
W -------------- ----------------------------------------------------------------------- •= -
UNature of pairs or Atka ons—Answer when gyp, tcable._.. _ �'.._. 1'1.:...-�� �_1..�J�✓ . ............
Sd' _�.... ------- -------------------- =�-�-•- -----=•--•-------•------- f------- -------••----------•-•---•-•- --------------
Agreeme t:
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 issue by h bo , of berth.
J
Sig dG.- 0 l =--- ------�"� ----- --.�---------------- ------------------------------
��1. /✓�fi! Date
Application Approved BY--------, ----- ---�----- ---•--._ _. .�-=f'--=L �---•----------------•------•- ----_°S_._ .2 C..-."-7 --
Date
Application Disapproved for the following reasons:-------•----------------------------------------------------------------------------•••---....-----...-•-------
----------------------------------------------------------------------------------------------------•----------------------------------------------------------------------------------------`--•------
Date
PermitNo........................................................ Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD nF HEALT
v
V J�........OF....... ..... ................. ...........................
�ertifirate of f"umphanrr
THIS IS IFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
Installer
has been installed in accordance with the provisions of . ,ti/i',cII XI of The State Sanitary Coe as described in the
application for Disposal Works Construction Permit No. �________________ dated__.-._ '_z__G.:-_:7__.............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------------------�= ---- Z'�............................... Inspector----
THE COMMONWEALTH OF MASSACHUS S
~�. BOARD OF HEALTH
6 r�
No.......f........... ,--t ,s FEE._..0
Permission is hereby granted. -----�J---------------------------------------------------------------------------------------- -•-•--••...-----
to Construct ( ) or Repair an Individual Sewage Disposal System _/
at No. �'� ��ti- P (�-,1`= ��z+� J--------- />f ��'z �tl G' L( i �(
y -------�--------------•-----
Street
as shown on the application for Disposal Works Construction Per it No_ ___.y � � G
......"..� J
Board of Healt
DATE --------------------------------------------
FORM 1255 HOSES & WARREN. INC.. PUBLISHERS