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Home My WebLink About0100 FIVE CORNERS ROAD - Health (2) O �O'9 �YJ P� ..o �D a(� No.. ... .... Fs>�.. .. .... THE COMMONWEALTH OF MASSACHUSETTS ®3 BOARD HEALTH /� -- .. .---.---.OP........ . ...... . ------------------------------------ Appliration for Eligpviial Workii Tonstrurtion Prrmit Application is hereby made for a Permit tp Construct ( ) or Repair (6') an Individual Sewage Disposal Pk3' System at: - .. . ...�'._ . .................'. •• - ...... ---.-- n Location-Address;44--- ot�OL�Q'o• - �' ----------------- ........ --------------- .................................................................................................. Owner ............................................Address r-a Installer Address dType of Building/ Size Lot........:...................Sq. feet aDwelling No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) pa Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures .................................. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 04 Septic Disposal Trench Tank—LiquidNo capacity......--__"gadthns LengthTotal Length Width...............TDial leaching area.._Depth._.....sq. ft. Seepage Pit No..................... Diameter____________________ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (' ) Dosing tank ( ) `-� Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit......:............. Depth to ground water----.................... ----------------------------•---•-=------•---------•---......_....-•-------........_......----------......................................................... 0 Description of Soil........................................................................................................................................................................ v --------------•---------------------------------------------•----..........---------------------•--•-------•--•-----------•-----------•-----------------------••-----•-------------------------------- W ---------------------•--------------------....--------------........---------------------------------- -•--- - --------------- V Nature of Repairs or,Alterations—Answe when applic 1 _-- - ---- --- -----............... .. _....._.. ----------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitar Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b e issued by the bo dfofhnith. Signed. .. . -_---- Date Application Approved By---... .. .__ . ....... .... .. .... .. ..... . . • - ate Application Disapproved for the following reasons--------------------------------------•----_.____._.___.....______._.___._._._........._...........-............. .................................•----------•--------------.......------------....------•---..........._._ ------------------ Date PermitNo.......................................................... Issued........................................................ Date No......................... Fu$.............................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ----------------------------------------OF........................... Apphration for Bioposa1 Works Tonstrurtion Pumit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ....-------•....................................................•----...............---•---••--•-- •••-••••-•-.....-••••••••.............•--......_......-•-...•••---•---............................ Location Address or Lot No. ........................••--•--.................----•--•------....-••-••-••••••---•----•--•-•--•-- •••••-•....--•-••••••....••••---•••-••-•-•-•••...---•- Owner Address Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons--.--.-.-------------.-.-_ Showers ( ) — Cafeteria ( ) dOther fixtures -•-•-•--••---•--------•---•-•--•------------------------------•--•----•-•----•------------------•------••-•-•••••-•------•-•-.......-----•-•-••-••--- W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter....----........ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter_---.-.------..---- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-----------------------•---•----...---•--•--•-•-••••......-•--•----•_.... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 4_1 Test Pit No. 2................minutes per inch Depth of Test Pit..--.--............. Depth to ground water.....---................ a •---------••--•------•------•-•-•-----•----••-----------•-••••-••-•-------•----------•-••-•--•--••••......................................................... 0 Description of Soil........................................................................................................................................................................ x U --------------------------------•...................------------------.............--------•----•------------------------------- --------------•-•--------------•--------------._....--•---•-•--•--•--•. W ----------------------------------------------------------------------------------------------------------------------------------------------------------------------............................. 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 been issued by the board of health. Signed...................................................................................... ................................ Date ApplicationApproved By.................................................................................................. ........................................ Date Application Disapproved for the following reasons--------------------------------------------------------•---------------------------•------•--•---•------•-•••... .......................••--•----•---•---.......----------••-••-•-•------••---••--........--•••-•••••......-•---•••-•-----••-----•-•-------•-----••-•-••-•----••--•----••---............................. Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH :11:? r ........OF..............., i.��. �.. Tntif ratr of Toutpltam THIS IS TO C aR TIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by....................... :..I ._....._.rC?� ��n�/{:�` �. Installer at.....<:......... ti. [Lc 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.............6.0-7............... 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 ..........................................OF..................................................................................... Permissionis hereby granted........................................................................................................................................ to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo..................... Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... ......---•--•-----------------=--------------- --- - --------•---------......---..........-•--_. Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS