HomeMy WebLinkAbout0076 SECOND WAY - Health �7(� Sew I,v� , 13G,rtisF�b1 e
C
No.._1e'......... Fes$.... :.................
• THE COMMONWEALTH OF MASSACHUSETTS
Ic� BOAR® OF HEALTH
.... ._PGUI............-OF......AZ/Z l?4q&* .�---------------------
--------------
Appliration for Disposal Workii Communion Pumil
Application is hereby made for a Permit to Construct (,,A) or Repair ( ) an Individual Sewage Disposal
System at:
-- I" --------••--• r ----•--
yLocation_Address y O y or Lot No. -B
.41.4---=- •--••••••----� 4lddres� � � ...
ner
W
P4 Installer Address
d Type of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms_____ _____________________ _____Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons____________________________ Showers — Cafeteria
p-' Other fixtu s,
W Design Flow________________ gallons per person per day. Total daily flow--------------------------------------------gallons.
W Septic Tank—Liquid Li uid ca acit jooa gallons Length Width--_.__.___..__. Diameter------- Depth---._--____-_--.
P q P Y------------g g
x Disposal Trench—No..........I ___.___ Width__.1 :-......... Total Length____,C_.7_6_ Total leaching area---- 7,�__sq. ft.
Seepage Pit No..................... Diameter.................... Depth below.inlet.................... Total leaching area------------------sq. ft.
Z Other Distribution box ()() Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date----------------------------------------
,� Test Pit No. 1_____JL-------minutes per inch Depth of Test Pit____________________ Depth to ground water._____-_-_-_-.___-_--.-.
(14 Test Pit No. 2......ta_......minutes per inch Depth of Test Pit____________________ Depth to ground water-______-__-____--_-__-_.
Ix •------------ -------------------------- --- ----- =
30P0 Description of Soil----------- -------------------------•-----------•-------------------�'---Al-«-- � �u'G ICI
x ----------------------C�-�0.+1G�L o ---.._lei.l_X G�._------------------------------------------
c.�
x -------------------- - .................. ---•-•---•--•--••-•-•--•-•----•-•---•-••--...---• 7�`' s ' 1" T------G� cti --/=/ =
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 bee .is ed b th bo r AoUiealthh.
Stgne _..
•-••7-
Application Approved BY � 7? r � ---
"`
Date
Application Disapproved for the following reasons-----------------------•------------------------•-------------------...----------------------------------------
-----•------------------------------------
// Date
Permit No....... .................................... Issued------- = -----••-••-•-•••-
Date
No_ a�_0.......... }?. .................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appliratilaxt for 43ispos tl urkii (omitrurtiou nutit
Application is hereby made for a Permit.to Construct (,A or Repair ( ) an Individual Sewage Disposal
System at: ,
fryx -gig: Srs , .....!- " ------------------------------------------
Location-Address + or Lot No. �y
r� �-- -------- f�--,r
Ot mer Address
W ,
Installer Address
d Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms_.:._2................................Expansion Attic ( ) Garbage Grinder ( )
a Other—Type of Building -------------t________-_____ No. of persons.-_________-___-__.___--__-- Showers ( ) — Cafeteria ( )
' 'Other fixilzres�
---- ............................
WDesign Flow---------------- . .................gallons per person per day. Total daily flow.~a.:...........................-------------gallons.
WSeptic Tank—Liquid capacity }l '_gallons Length----_---------- Width__---------------- Diameter---------------- Depth----------------
Disposal Trench—No.---------g .. Width. .,-----_:-__ Total Length..._.. ' 1 otal leaching`area._.. ,�"�_sq. ft.
Seepage Pit No--_----------------- Diameter.___..........._... Depth below inlet..................... Total leaching area-__---_._--_-.._-Sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date----------------------------------------
Test Pit No. 1-----6--------minutes per inch Depth of Test Pit.................... Depth to ground water.--__---__-____-_-_.----
f� Test Pit No. 2..... .,.......minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
W
---•-------.-p--------------••-----------------------•--•-----•-----------------••----•--_-•---•.�..�.------•-•,-
,--•'•�•--•••-•••-r--�-�----...----•---•-----•--•------.
••-•----•••----•--------•---ODescri Description of Soil
Ux ---------------- a .
> � •-------------
4'2---------�. ...... = ;� s-----
UNature 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 bee •is ed b th board of health.
Sign . s. - ----- - -�
d� Date
Application Approved By- �;; --sd Date
-- i r
Application Disapproved for the following reasons:---------•-------•-•-----•-•----................---------------------------•-------------- ......................
--••--••••---••-----------••-•---•--------•-•-•----------------•-•-•------•-----•--•••-----•---••--•--------------•-----•-•-----•••---•---•••-••---•-----------------------•----------•••-•---•------..
Date
Permit No. "---------------------------•-------•-------.--- Issued.------ z � �? `� ...................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........................:.OF..... ,µ:,....... .,.. . ..Z� .....................................
Tntifiratr of Tompliaurr
THIS IS TO CERTIFY; That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
bY--------------------------------------------------------------------------------------------- -----------------------------------------------........................................................
Installer
at= 3 F G, Ji !---------- G, y e C....•--••---•--------------------------•--
has been installer) in accordance with the provisions of Article XI of The State Sanitary Code a" described in the
application for Disposal Works Construction Permit.No...__ _____________•---- dated................................................
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 OF HEALTH
1 ..• .........................:......
No........... FEE....................
- inpurial, larko C omitrurtion prutit
Permission is•hereby granted_::- •-•---......:.------- --------------------------- -- -------••------•--•-•-...--•-••......-•-----_..
to Construct�( ) or Repair ( ) an Individual `Sewage Disposal System
at - ---- --------- ---------------•-•-
x Street
as shown on the application for Disposal Works Construction Permit No.t ____ Dated-----
! E+
-•-•-----•---------------------•-----•-•--------------•------------••-----------•-•--•---------------
Board U Health
.DATE.---•---------------=-----------------•----
FORM 1255 HOBBS & WARREEN. INC.. PUBLISHERS