Loading...
178 Applications & Permits No THE COMMONWEALTH OF MASSACHUSETTS n n, BOARD/ OFF HEALTH �/ % OF ,UJ l( 9 /r 74/ F SG.at /tie) ,ae.,Cee 33.40 APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTIOS),PF NIIyT��� ) - u Complete System nddntdua /omponenC 4"ec iwnon for a Permit o Construct f I Repair ( Upgrade ( ) Abandon I ••- / 'g 1e f / . • }/ o --si,too, - intim ct a, / 7? dfr-s- '?7Ant=er•v/et) �,>„.o. mnvle�n.0 A.prF%4rn/> >1 Gto 7J f Ae%}7/4 . S M td Y ,e�ePaen�x ltaucIt{at- IS//_4 -lien7- Es g/2 eDemgnersName %F AdUr... ldephane: CI-M4-44 L.: rifa;70 n),fr QU 4 III 3— • S57`-2- 2/ ldcPannex Type of Building: - frL-j7jviNt Lot Size Sq.feet Dwelling *No.of Bedrooms t zt Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ). Cafeteria ( ) Other fixtures Design Flow(min. Plan: D Title fired) 4 • r ' d Calculated Dam fug of Soils) �rO UQ I 547j.b Name of Soil Description Soil Evaluator Form No. Number of sheets DESCRIPTION OF REPAIRS OR ALTERATIONS • ' 1 •• __ e/a • • design fl i L o Revision D i' C :rI r — valuate Date of Evaluation afn Design fl gpd A- aesiiigair u / • L• 2 The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Inspection Date FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 No. 494,11f :4 THE COMMONWEALTH OF MASSACHUSETTS J /Un 440ALBOARD OF HEALTH CERTIFICATE OF COMPLIANCE mplete System /_Jt by certify that the Sewage Disposal System:Constructed( ).Repaired( .Upgraded( ).Abandoned( ) G9Q�cil� Description of Work: The undersigned by : lC /7 Individual Component(s) FEE i” 12/ od �nr., /may,''';: %n✓l /r t t 7 { iZ t' S- Dr--c. at h b installed 'n accordance with the provisions of 31f1 C it t5.00 ( le 5) and the approved design plpn)s( built :-� / T �IV// Installer c- . / - . MA — y ! z� /) t z dl ��nspcctor / Jij Date u r. .�t 1 %/ Designer: iI) [[[„,,nb The issuance of this dertificate shall not be construed as a guKranrea that the system will function as desigded. has been 1 plans relating to application No.i�i90 ll-,�� dated LQ 7 7) . Approved Design Flow (gpd) FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 No g -ny( s lEj THE COMMONWEALTH OF MASSACHUSETTS ,OO8y7Jlf/I /HOARD OF HEALTH FEE r" 4/ DISPOSAL SYSTEM CONSTJICJCTION PERMIT Permission is hereby granted to Construct ( ) Repair ( Upgrade ( ) Abandon ( ) an individual sewage disposal system at /77(e b,i G F t A.� (_ [,�- r�co Z'1'�s derscribed U � dated a / �)7 in the application for Disposal System Construction Permit No. Provided: Construct on shall�be completed within three years of the date of this pen ' All Iocal,conditions Board of Health I/I �. '�. c - Date 0 "7 nf� FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 IREV 5/961 �IItWI) HOBes&WARREN.' NEE PUBLISHERS - BOSTON he met. No «3 THE COMMONWEALTH OF MASSACHUSETTS e�OARDOF� QHEALTH OF ....� .u. .rt.'^u'. Applira1iun -fur Uiu}tuuttl 1flurk0 k!Iuualruth it lirruttt Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Faa `-� ' C Y [ System at: .T' �� /�_ _ fir or Lot No. C-tAk atbrunt.//i t,:tate` Size Lot Sq. feet Type of Dwelling Building Expansion Attic ( ) Garbage Grinder ( ) Otr—Type of Bedrooms Po — Cafeteria ( )— Other—Type of building No. of persons Showers ( ) Other fixtures gallon. Design Flow gallons per person per day. Total daily flow — Depth gallons Length Wild: Diameter p Septic l uk—f—N capacity gir 'fond leaching area Width 'Dotal Length Disposal Pit No—No. Depth below inlet Total leaching are- sq. ti. Seepage Pit No Diameter i Other Distribution box ( ) Dosing tank ( ) Date Percolation Test Results Performed by - Depth to ground water_ Test Pit No. 1 minutes per inch Depth of Test Pit 7 g Test Pit No. minutes per inch Depth of "1 ea Pit Depth to ground water Address Address Description of Soil Nature of Repairs or Alterations—Answer when applicable toaeP Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article AI 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. Signed- y � f ,l 47 Application Approved By �i�"-°'/�°4�"-- I/ J • I_. Date Application Disapproved for the foFlovsn,V reasons: / Issued 4- 1 ] 7 Permit No.-.1/" Date by of (Itnm�thuntP or Repaired THIS S TO CERILFYg,TIwt the Individual Sewage Disposal System constructed ( ) p (4/ at 1.1 C /i 3 `= has been installed in accordance with the provisions of Article XI State Sanitary application for Disposal Works Construction Permit No !C dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A SYSTEM WILL FUNCTION SATISFACTORY. DATF (Britt-titan) 1 nstaller $ 192.7 No. Inspector Qr. . tla:_ir� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF Code as described in the ,12-e-1.41 UARANTEE THAT THE -r Bispnsttl ifinrks QInitatruttinn 1JPrmit FEE Permission is hereby aiante4e to Construct ( ) or Repair (✓) an Individual Sewage Disposal System at No t . Street as shown on the application for Disposal \Vorks Construction Permit No DATE FORM 1255 HOBOS & WARREN. I PUBLISHERS Dated Eon rd of Meant/ - f No THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF Fss....._............._._..... Applitntion for Disposal rr;arks «ionstrurtion 1rrmit Application is hereby made for a Permit to Construct ( ) or Repair (V) an Individual Sewage Disposal System at: Location-Address Ow7je, i.... installer Type of Building Dwelling—No. of Bedrooms Other—Type of Building No. of persons Other fixtures Design Flow gallons p Septic Tank—Liquid capacity gallons Disposal Trench—No Width Seepage Pit No Diameter Other Distribution box ( ) Dosing Percolation Test Results Performed by Test Pit No. 1 minutes per inch Depth of Test Pit Test Pit No. 2 minutes per inch Depth of Test Pit or Lot No. Address Expansion Attic ( Address Size Lot Sq. feet Garbage Grinder ( ) Showers ( ) — Cafeteria ( ) er person per day. Total daily flow gallons. Length Width Diameter Depth Total Length Total leaching area sq. ft. Depth below inlet Total leaching area . sq. ft. tank ( ) Description of Soil Date Depth to ground water Depth to ground water Nature of Repairs or Alterations—Answer when applicable :e.„4.44;w1s r' 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. Signed Application Approved By Date Application Disapproved for the following reasons' Permit No Issued Dam THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF. ' Qtrr ..'� .fr...,.....I1`.il tifuutr_nf fQnmplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( by Installer at 1--i...f......._It....:t 2:2.ess.r... has been installed in accordance with the provisions of Article XI of The State Sanitary Code as 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 J-! ;Lbw . - No .M1 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH F Disposal new kinnstrurtiun jrrmit Permission is hereby granted ` to Construct ( ) or Repair ( •")^an Individual Sewagg.Disposal System at No L Street as shown on the application for Disposal Works Construction Permit No DATE ',jaw" ' �l FORM 1255 HOBBS & WARREN. INC., PURL/SHOOS Dated FEE Board of.'Health