HomeMy WebLinkAbout0077 HEADWATERS ROAD - Health 77 Headwaters Road
Centerville
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No. 42101/3 ORA
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ESSELTE
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No. ........5`S Fss...✓.. .................
THE COMMONWEALTH OF MASSACHUSETTS"i,
BOAR® OF HEALTH
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Applir�ation for UhipwiFal larks C�nni#rurtion Frrutit
Application is hereby made for a Permit to Construct ( ) or Repair (�( ) an Individual Sewage Disposal
System ht640(J 4e_o /
rf r/ AZ 0w,,P,iw.e S �l� u'i t�(�
•••_y, --_------------------•---••-•--- .4. ---------------- ----.--.........--•------.........- ..........._
/ 1 A Location-Add�ss or Lot No.
. ��mL° ........... ............................
Owner
Address
�TL�v.. ,c_
Installer Address
d Type of Building Size Lot............................Sq. feet
Dwelling 1f?"No. of Bedrooms.....3.................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons.................._......... Showers ( ) — Cafeteria ( )
d .=
Other fixtures -------------------------------•-----...---------------•••----•---••-•----------------------•--•-----•••••••--••••-•.......---•••......•-•---•-•••-•-
WDesign Flow................. .................gallons per person per day. Total daily flow_______.-..-S b-4. ja.................gallons.
WSeptic Tank—Liquid*capacitylo®..gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width_.........._._._.. Total Length............?....... Total leaching area....................sq. ft.
Seepage Pit No......�4.-----__-- Diameter.._.8._- ..... Depth below inlet....!!�-......._... Total leaching area..4a44:.....sq. ft.
z Other Distribution box ()() Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
ram, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a' - p
0 Description of Soil.... '/stGG �� '7...........1if.DXy------ v .........................................................
U
-/ ---�'------�'�t�T! --------1�-��-��-- —A✓a..._.o ------ 6 ------------
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-- ------/°•...AS/Gtri--�g...............!-oc........... ..../_/►' ...... •--- .....................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT Li 5 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 oard of he
Signed---... ....... .•-•-•-•...........
Date
Application Approved By......................
............
Date
Application Disapproved for the following reasons:------•-----•••-•----------•-•--•••-----------------•••------•••---------•••--••---....._..-•---•-------••-••--
..------•-•------••-•.-•••-••-••••--••-----•••--------------••-•------•-----------•_..
Date
PermitNo......................................................... Issued.......................................................
Date
-xo
NoNo.-------••-•-........ of
................
THE COMMONWEALTH OF MASSACHUSETT41�
BOARD OF HEALTH
........................ . .............O F................................_..........----------.....--------------...I..............
Apptiratiun for Disposal Works Toatutrurtion ".truth
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
................_......_...................................................................... ......._._...--•----••------••--••---.....-•--••......_----...-•-•----------•-----..............•-
Location-Address or Lot No.
......................—.......................................................................... .._.....••----........---•---------........._...................-•••-•--••........-....--••---•---
Owner Address
W
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Pk Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
p t Other fixtures 94 N-----------------------------------------------------
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 Lenith.................... 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........................................
-a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fT Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 -----------------------------------------------------------•---.....---------------•-•----•--•--.............---•-•----....--------••-••---------•-•---__•---
0 Description of Soil.........................................:...............................................................................................................................
t ................,
UNature of Repairs or Alterations—Answer when applicable................................................................................................
- ---------------------------------------------------•-----•-•---------------------------...........-•----...---------------------------•-----------------------........................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Dispbsal System in accordance with
the provisions of TITIE 5 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.....................................C
-•••-•......-••---•......_---•--
Date
Application Approved By...................... .................
Date
Application Disapproved for the following reasons--------------------------------------------------------------------------------------------------•••--------•--
---------------------------------•--•--------------•••--••-•--•-----••--••••••`--•-----•-•••••••....._...---•-------•-•••-------•-•--------•----•--•----•••----•--•-------------•--•---•--•••-----------
Date
PermitNo.................................................y--..... Issued.......................................................
Date `
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF..............................................................I......................
Curdifiratr of ToutpliFanre
THIS IS TO C 1IFo ndividual Sewage Disposal System constructed ( ) or Repaired ( )
y.................................. .... 17
......._. ......_._. ._._ ._
k; �� ��• Installer
t
has been installed in accordance with the provisions of TI a5,+��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........... _� 7..................f.......................................d Inspector..... .:_.:...4
. ••-•-------••••..............................
THE COMMONWEALTH OF MASSACHUSETTS
/�r� BOARD OF HEALTH
...............................I.........OF..................................................................................... 101
No......................... FEE........................
Disposal F*rftxfAW*udion Vvrrutit
Permissionis hereby granted-------•-------------------------------------------•••---•-•-----•--•----•••---•-•• .................................................
to Construct (�i o Rep � ual�Dispos ysteN^ ;1✓/
atNo....................................................................---•••-•-•-•-----•-----•••.-•••••----•--•-••-------•-•-•---••--••-------•-•---•••-••-••--•-----•-----------•--•--•-••-__•-
Street
,as shown on the application for Disposal Works Construction Per ........:........... Dated...........................................
...................................................... ..................................................
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS - -
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