HomeMy WebLinkAbout0070 GUILDFORD ROAD - Health (2) IV GwACT)2d VZ000k
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/// SMEAD
No_ 103?A.
2-153L
MADE IN USA
GET 0017,ANIZED AT SMEA I-COU
s
No....2:71)......... Fim..... ..
THE COMMONWEALTH OF MASSACH-yU�SETTS
BOAR
...
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72 d
Aplifirativit for Uiiipos tf Works Tomitrur#ton ramit
Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal
System a //
....... . .. ... .. ... . ......... ..........................
.................
.............f�-=.�� .. ..tio�s ............................... ..... .� ...or Lot•No.......................................__.
.. .. !\. ..............
ner
Installer Address
UType of uilding Size Lot....� .._..Sq. feet
�-, Dwelling—No. of Bedrooms............... . ........................Expansion Attic ( ) Garbage Grinder ( )
a a Other—TYPe of Building --- ----------- ------- o. of persons......4................... Showers
( ) — Cafeteria ( )
Other fixtures
W Design Flow.... ..............................gallons per person per day. Total daily flow..... ------_-----.._--.. _--_-_-gallons.
WSeptic Tank—Liquid capacity./t?-O._gallons Length................ Width_...._......... Diameter................ Depth................
x Disposal Trench—No..................... Wide . Total Length.................... Total leaching area-_____Q_----------sq. ft.
,> Seepage Pit No--------------_---- Diameter._..._e Depth below inlet..... ....�./- Total leaching areaS___..)......sq. ft.
Z Other Distribution box ( ) osing tank ( ) �. ��-(rK» '-7-
a Percolation Test Results Performed by.........................................................................I Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.--_----_-_-__-_-__-----
f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
- ......................................................................................--
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 under gn d further agrees not to place the system in
operation until a Certificate of Compliance has been ity
the rd th. 1,�Signed---. _.-- •-• . _ ......... f• -2�
Date
ApplicationApproved BY-----------------------------------------------..................................................
Date................
Application Disapproved for the following reasons:......................................................
-----•-•--••._....
Date
Permit No. Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HE LTH
!,lj
Appliratinn for Biquas tl Ends Tonntrurtinn Vantit
Application is hereby made for a Permi,,,trrrto Constructs . ) or Repair ( } an Individual Sewage Disposal
System a .�. ..... ..... ..... ,
ffff' i iT., n Addres , l r' ..1 or Lot No.
.............:eD}. Tr ,:$rr� 5.1. `. r.. ..�^"' �:`:- ...........,......... t: ...: ............................................................
1 ner r PAdA. ss
a ............. ' j' �:�-,✓..�.:... 1:..r�. r-"'e:. -`` ......................... ''1 �:.:.........................? �.�E.......• � .•..........._...................._.......__.
.;�'
Installer Address
d Type of`Building Size Lot-------__-___1?'%`="._..._Sq. feet
U
�- Dwelling—No. of Bedrooms..............; _..__Ex Expansion Attic Garcia e Grinder
f e............... p ( ) g ( )
114 Other—Type of Building ...la�?<"��:'::"-��To. of persons.....--.................... Showers ( ) — Cafeteria ( )
a t :
d Other fixtures ------------------------��------•--------------•-------•-----------••---------------...----......._..--------------.__...-------------._.....-------
W Design Flow..............-
........................ per person per day. Total daily flow------_--:Z:a.............................gallons.
WSeptic Tank—Liquid capacity_,/:^:.gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No...:................. Widths__. _ ........... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter < `` ` '� _. Total leaching area '�' .__.___sq. ft.
r, Depth below inlet
z Other Distribution box ( i) Dosing tank
aPercolation Test Results Performed by_________________________________________________________________________ Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
f,4 Test Pit No. 2......._........minutes per inch Depth of Test Pit---_................ Depth to ground water........................
0 Description of Soil---------��-__�,S:.yf_. '�...-•-------•----------------------------------------------------•----•---------•--........-------•-•-------
x :.-. -
w -------------------•------------------------------------------------•-•-------------------------------......
U ...........................................•••....-----••---•••..__...---•-•••---•-•-•--•-•-•••-•--•-•••--•--••-•-•----••--•••--•--•-•-•-•••----•---•••------------•----•-•----------..__...---•---------
W
x •-•-------------•------••------•••-•-------•-----•--•••--•--•-----------••--•••---•-•----------••---•----------•------------••--••••-•------•-•-•-•-••--•------••-•--••----•-----•-•••••--•.........--•-
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 Code—The under gn�d further agrees not to place the system in
operation until a Certificate of Compliance has been ss�le by theft` rd 4'f/health.
Signed. --_�1_k : : d � .>�
Date
Application Approved By.................................................................................................
r�
Date
Application Disapproved for the following reasons:................................................................................................................