HomeMy WebLinkAbout0028 CEDRIC ROAD - Health IF 28 Ced9 Road a
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No.2-153LOR
UPC 12534
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THE COMMONWEALTH OF MASSACHUSETTS
�y BOARD OF HEALTH. - .ra'( lu------- ---------OF'...... ........... .....:..... .
Appliratian for Disposal Works Tonstrurtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
4
System at,
T... ........... .... .... A............................
orafo Address or Lot No.
.........••--.... � ..� 3°.t�f�..___. ................ ....... .-• ......� !�A!4 .
ne __ - Address
a •----•-•------••--biinggA*"L
......... -•. . .................. ••-------••......--• �ld4/ex... ..__...._.... 4`'. _D_---._•.•_--------•------•-•---------------
Installer Address
UType of B Size Lot...1S49�?.........Sq. feet
Dwelling—No. of Bedrooms..........................__-.........Expansion Attic ( ) Garbage Grinder ( )
Other—Type
ype of Building --------f�p� o........ N . of.persons............. ............ Showers ( ) = Cafeteria ( )
Otherfixtures ....................................-..........................----.....•---•-••-•--•-••------••------•-•------•••--•-•-•--•-••--•--•••••--•••••-----
W Design Flow.................. __._...___ ____._..gallons per person per day. Total daily flow..........31M.........................gallons.
WSeptic Tank-Liquid capacity�.�--6�__.'-gallons Length................ Width................ Diameter................ Depth............
x Disposal Trench—No..................... WidthPsingg'"'tank
....... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No -----• Diameter-tD
Depth below inlet--•••-••-•--•----_.. Total leaching area...®.- -.s ft.
� 1------ P g --- -- q•
Z Other Distribution box ( ) ( )
aPercolation Test Results Performed bY.......................................................................... Date........................................
Test Pit No. I----------------minutes per inch Depth of Test Pit.................... Depth to ground water____-_______.___-____._.
44 Test Pit No. 2................minutes per inch Depth of Test Pit........_........... Depth to ground water........................
...
----------
ODescription of Soil....... =moo -------------•------------------------------ -----------------•--•-------------------...-•••-----•---••••.....-•••
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c_� .•••-••---•-....-•••--•-•••-•----•-••--•-•--•-•-•---•--•-••••........-••-••-•----•--•--•••••--•••-•-•-••-•-•-•••--------•--••-•••----••--•-••-----•-•••-•-•----•----•••••--•....._---•--------•---.---••-
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--------------------------------------------------------------------------------------------------------•---••••------------••--•---------•-•--••--•...-•--••..........................................
U 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 Cod The undersigned further agrees not to place the system in
operation until a Certificate of Compliance ihasbeen ed bye d of health.
SiaQ............. •.....................•--••--•- ................................
D/1e _
Application Approved BY ,� = � D
-7 .
Application Disapproved for the following reasons:..-------------- ---- . -- . ------------------•--•-------------........................._..
----------------------•--------•-•-•---...-------•----------•-------...._..---------••-•----------.•......------------....----------------------•----------------- ••-•••---•-•.....--•---•=..._-----•
Date
PermitNo.......................................................... Issued........................................................
Date
No......................... Fim............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
4,00V................ OF.......
Appliration for 31-sposal Work. . Tonstrurtion "Pratit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at,
...............,::Aid ....... .
. ......... . ....f.. .......... ... .............. ..........................
Location-Address or Lot No.
.............11 -
Jot'l , 4 "� ..............................................
4="�&Ve 2.AX...j...... .................. .......
qhyne Address
A
................... .................. .... wff!At�.....(.
.. ....�,� g--, �..... .........................................
Installer Address
Type of Budding Size Lot.._.. f:ii:M. ........Sq. feet
U
Dwelling—No. of Bedrooms.................2�......................Expansion Attic Garbage Grinder
aOther—Type of Building ........ ........ No. of persons.............IC....._..... Showers Cafeteria
Otherfixtures ......................................................................................................................................................
--tll C_
W Design Flow....................L��...... gallons per person per day. Total daily flow...........3tf�4.........................gallons.
W4 Septic Tank—Liquid capacity/;.big' allons Length................ Width...._...._...... Diameter........_.._..__ Depth....._....._....
Disposal Trench—No..................... Width.... Total Length._............._._.. Total leaching area__..................sq. f t.
Seepage Pit No........i........... Depth below inlet.................... Total leaching area_.. ...sq. f t.
Z Other Distribution box Dasing tank
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit...--_.............. Depth to ground water------------------------
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water___...._.........______.
0
0 --------- -----------------------------------------------------------------------------------------------------------------
..........�4i �
Descriptionof Sol......... .......?n�.................................................... .................................................................
U ......................................................................................................................................................................................................
........................................................................................................................................................................................................
U 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 Cod —The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ed by P"e d of health.
ne
Date
........... .21
_Z/-.::?- D a e
Application Approved By----- ....... -----
Application Disapproved for the following reasons:....................
................................
...................................................... ....................................
.........................................................................................................................................................................................................
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD.. 0 HEALTH
.................
OF.:.....
............................................................ ...
(Intifirate of Toutplitt"r
THIS-IS TO CERY-�Y:,,12hat the Individual Sewage Disposal System constructed Repaired
i I , - i
by............ ........................ ..................................................................................................
- 7 Installer
at- ----------
--------------------------....................................................................
- --------- - --------�j------- --------------------
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as desc ibed 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............. ..................................... Ins.pector...PC 6 1)..........................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALT!J_,,
0 F...........fi ..............................
✓
No
FEE....,*...............
13WVviial-Morlm �lt
Permission is,hereby granted........ ....... ... .............. .....................
..................................................
to Construct air� an�;�tj�ividua e-wdge Disposal Syster�
at No....................Zr
Street
I , 7 Z
as shown on the application for Disposal Works Construction Pexinit.No... Dated...... -� .........
..............
............ZA�.............
...........................
Board of Health/
DATE.................................................................................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS