HomeMy WebLinkAbout0013 HARBOR HILLS ROAD - Health (3 NAfibot �11tS I`d
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD QF HEALTH
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Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
Location-Address or Lot No.
Owner Address ;
Address
Other Distribution box ( ) - Dosing tank ( )
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
_2alth.
Date
Date
,
Date
Permit Issued......................................... ..........
Date -
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LOCATION 5EW&C4E PERMIT MO.
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IMS`TQLLER 5 1 &MF- ADDRESS
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bUILDERS 1.1L MF- ADDRESS
DATE PERMIT 15SUED
D ATE COMPLI &DICE ISSUED : � �' �
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No. ... d.. Flms.... .......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARDPF HEALTH
..........OF................ .�2 � �........................
,1pVtiration -fur Uiiipaott1 Workii TaQ>tti t artion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
jI Location_Address or Lot No.
...
Owner Address
W
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms---------::9.............................Expansion Attic ( ) Garbage Grinder ( )
aOther
—Type of Building ____________________________ No. of persons.--------------------------- Showers ( ) — Cafeteria ( )
dOther fix,lures --------------••-••---------------------•--•------------------------------------------------------------------------------ -••--••-•••---------------
W Design Flow-------_'7Z ------_..................gallons per person per day. Total daily flow__.__.__..__.J_r_.v....._........-....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 ( )
a .Percolation Test Results Performed by-------------------------------------------- -------••--••---------------- Date-----____------------------------------
,� Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water-..--.------.--.--------
fs. Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water----------------------
Ix -----------•-----------------------------------------•-•---------------••----------------------•---.........................................................
0 Description of Soil........................................................................................... ---------------------------------------------- -----------------------------
x
w
x -------------- --------- ---------------------------------------------- ---------------------------- ------
U Nature,�c f Repairs or Alterations—Answer when applicable................................................................................................
l l 1- '! /r ----- /_ S, .o ---- •--•-•-•--n ' '1
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.
Signe ......-•= •--'..__.: %:9% _. ---------------••-•----•--• ................................
Date
A Approved PProved B Y------ �- -----�- --..=�_�'//l1.1i_l�t------- - C �.r-� ...........
Date
Application Disapproved for the following reasons:-------------------------------------------------------------------------•-__-_------_____-_--------------------
---••--------------------------------------••--•••-----------•----------•----•-------------•------------ •--•-_-••--•----------------•-•-•-------------------•----------•--------
Date
PermitNo-_____-`................................................. Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.....�•�. /ln...........OF_..._......��..r,�4-Y �
...............
Qwrtifiratae of f"oantliliolnrae
TH IS TO CERT�HTthe Individual Sewage Disposal System constructed ( ) or Repaired
by �� ---- ---•••--•••-•-•----- -•--•--------------
-------
I tal r l � /)
at-- --- -� �f - -
has been installed in accordance with the provisions of . ti 1 XI of The State Sanitary ode as described in the
application for Disposal Works Construction Permit No_____________ ....... ..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ,o(!r------- 'a� Inspector----- ... - -------
THE COMMONWEALTH OF MASSACH TS
C7/ 1 6- BOARD OfHEALT
G —'e .. ...........OF....... rnJ
--•-•----•- FEE...------...............
io -1 Markii T ptrrawnrrutit
Permission is hereby granted.__% .___ !1�1 ..,1___._.
- •---••-------...-•------••••-----•---••-• --..
to Constr ct-,( ) or epair ( "I'an Individual Sewage i ,al S to
i.�a f�at No.- .1�-- '!--lCl 61
- f ;` r%/ - �-=--- /
Street _
as shown on the application for Disposal Works Construction Per�No._._..__r_.J.___ Dated___. ._�_ ..........................
.7 ------ oa ac
DATE. - Z-'-�'------- — -�-------------------------------------------------------
d of Health
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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