HomeMy WebLinkAbout0345 MIDPINE RD - Health E9-
B Midpine
Barnstab(e
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No.......... Fimg.. .............r....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/`' ►�1......oF..--... .... �-----------------------------------_...----.....
-Appliration -for IM-4p iial Workii Towi#rurtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
7 -•-••-------------•••--•---------------•--•-•-•--•--------------------.......•---••-•-----•----.
p
oSattion-Address or,Lot No.
Ow, }--' e, Address
a ---------- �� f"� .... j % —
� Installers Address
Q Type of Building /Size Lot----------------------------Sq. feet
Dwelling—No. of Bedrooms_.-_-_-_.--c-----_______________________Expansion Attic (y ) Garbage Grinder ( )
p, Other—Type of Building ---- _�'- � _. No. of persons---------------------------- Showers ( — Cafeteria ( )
04 Other fixtures ----�----------------------- --
--------
W Design Flow..................... ..................gallons per person per day. Total daily flow------ .__....___..--__-_-___--..-.-.--.gallons.
WSeptic Tank-�Liquid capacity/01gallons Length---------------- Width................ Diameter-----...._.----- Depth_.-.___.. ---
Disposal Trench—No-_______________ ____ Width____._______ _ Total en th_- __. Total leaching area--------------------sq. ft.
Seepage Pit No r------------ Diameter... .. v ,�+ ,_'r�_... Total leaching area sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) X v � _ y"2 Q- 7J`
aPercolation Test Results Performed by-------- -- ---------------------------•------•---------------•-----•----- Date----------------------------------------
Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water---------.._.---__.--_
(�4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-----.-_-_-.--.-__--__--
µ{ ....-.1......... Y ......... fDescriptionof
Soil- � ��,......----- A +�U --------------- - �'� �' - - ------ ----------- ---------------------------------
x --------------------------------------- --------------------------------------------------------------.--------------------------------
U Nature of Repairs or Alterations—Answer when applicable--------------------------------------------------.-._-..----_--_--_..---------.------------
--------------------------------------------------------------------------------------------------------------------------------------------- -------------•---------------------------------------.....
Agreement:
The undersigned agrees to install the afore' edua Sewage Disposal System in accordance with
the provisions of Article \I of the State Sanitary C 1,e— The undersig ed further agrees not to place the system in
operation until a Certificate of Compliance has In ssue the board f health. �'y
- '
Sig ed.. -\ �i Qx'` �- '' ------ - -.� ------`- :�
Date
Application Approved By------ -- ..................... ......e.-=-; /./-7j`--
Date
Application Disapproved for the following reasons------------------------------------------------------------------------------------------ a
---------------------------------------------------------------------------------------------------------------•------------- --------------------------------------------------------------------------
Date
PermitNo......................................................... Issued........................................................
Date
-Jib
No......................... FEiz 0..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF; HEALTH
vl. oF....-"'".... .... -----------
Application -for Uiopoottl Norkfi Tonfitrortioo Vaulit
Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal
System at:
.........
oc�ion-Address or Lot No.
��---•-�._l_.._ .LSI..IY..
Ow..�. -•-•--•--•---------------------•---•-----•--Address
Installer Address
d Type of Building Size Lot____________________________Sq. feet
Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ✓) Garbage Grinder ( )
a, Other—Type of Building ---�___, tit': __ No. of persons____________________________ Showers Cafeteria ( )
0.1 Other fixtures ------------•-----•------------ - -
Desi n Flow.................... gallons per person per day. Total daily flow.._..-2..V ____'....._... Mons.
W g g P P P Y Y g�
WSeptic Tank-�Liquid capacitv//__V_gallons Length................ Widtl ..._............ Diameter----.----------- Depth____.____.--.
x Disposal Trench—No_____________________ Widtli.____________-. Total ength . Total leaching area--------------------Sq. ft.
Seepage Pit No-------/............ Diameter-/ �----�� re-
-- - Total leaching area.----.._..------_sq. ft.
z Other Distribution box ( ) Dosing tank ( ) /�� - 1-.2 9- T 1—
aPercolation Test Results Performed by-••______________......................................................... Date-------------------------.----------.-..
Test Pit No. 1----------------minutes per inch Depth of "Pest Pit_.-_-____•__________ Depth to ground water._..___.._._-..._......-
f14 Test Pit No. 2................minutes per inch Depth of Test Pit.-__________________ Depth to ground water------------------------
Ix -•-------5.....-- t.............--,
___. __._
Description of Soil - ---•-..-1 :•_..� /.?zE .
V ......................... f�`'`f — 1� 5 -------------- ----------------
W -------------------------------- --- ------r..
------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable.................._------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the afore,el Iidual\Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Co`,e he undersig ed further agrees not to place the system in
operation until a Certificate of Compliance has b en ssued the board f health.
Si g9 ed.......- --• -- .......... ... ------------ �' �': �J------
Date
Application Approved BY------ ---- �' t =._ /.��
Date
Application Disapproved for the following reasons---------------------- ----------------------------- ...........................................................
------------------------------------------------------------------------------------------------------•-----------------------------------------------------------------------------------------------
Date
PermitNo......................................................... Issued........................................................
Date
i
THE COMMONWEALTH;OF MASSACHUSETTS
BOARD Of iEALTH
......................OF.................. 1�...`....'...................................
0.1rrtifirate of f�omstiattre
THIS IS TO "IIFI', That Ind vidual Sewage Disposal System constructed or Repaired ( )
by
<+ r
----
In taller
has been installed in accordance with the provisions of _ 'c_ XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ZS .___�:.7�___.__._.._ dated.... _-__ __�._'_71_--...____.__.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
75
7b- ............ ...... ... ..of.................... ...............................................
No......................... FEEJO.............
%spolia ork.q Cllonii rurtion rrrmit
Permission i h reby granted................ l__ �_.•_ at E...
................................... ..............................
to Cons ct (t or Re air (I an Infivirl ual Z7ge Dis)oral System
at No./ �/"Ll.��lt... C<�
Street ,
as shown on the application for Disposal Works Construction Per It No.. ated..�__--�_�.-.7_S ............
Board of Health
DATE • i�-•-.... -----------------------------------
--- ---1255 HOBBS & WARREN, INC.. PUBLISHERS
CE�2r, F/ED PLoT PLAN
/V .0009T/0ni CU/yMAQViD MASS.
sC�9tE /�_ ¢off DATE Au6u5T. /9 /97S
REF. /3EiNG ,CoT /S9B
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PR►VATE.