HomeMy WebLinkAbout0340 OLD STAGE ROAD - Health 340 OLD STAGE RD
Centerville
A = 190 - 256
SMEAD
KEEPING YOU ORGANIZED
No. 12534
2-1WR
�aoewuso�
GETOIiI;AI�ATgYEAD.�OY
/ 0 F .........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
o _row tj.............. ............................
APPUration for Disposal Works Tutuarurtion rantit
Application is hereby made for a Permit to Construct ( L-1 or Repair Repair an Individual Sewage Disposal
System at: A
.....................lq. �'1 ..... T;Ve.....RZ)...... ---V/...............................Lem........Z..................
Location-Address or Lot No.
. ...................................... .......S.A4.0------ ------------------------""--------------*---------------------------------
0 Address
..........
............................. _.Y&Q......AAL..To........ ..................................................................................................
Installer Address
Type of Building Size Lot............f..01I.Sq. feet
Dwelling—No. of Bedrooms.................S----------------------Expansion Attic Garbage Grinder
Other—Type of Building ............................ No. of persons_......._.__._.......__.__.. Showers Cafeteria
Otherfixtures .................................................................................................................. . ...................
Design Flow................... 'gallons per person per day. Total daily flow......................3.3_6......gallons.
1:4 Septic Tank—Liquid capacity gallons Length................ Width............._.. Diameter._.............. Depth.....__.........
Disposal Trench—No. .............. Width____._ ........ Total Length...... ... Total leaching area--------------------sq. f t.
Seepage Pit No----------/-------- Diameter.-__-___-_ Depth below inlet... &)-.,.-..... Total leaching area... &o..sq. ft.
Z Other Distribution box Dosing -)C .+, A I tank (�- .
Percolation Test Results Performed by.. Y15............................. Date.....#!ft/.n 19.
14 Test Pit No. I....*AZ..a�...minutes per inch Depth of Test Pit------ Depth to ground water---. -----—_
04
�T4 Test Pit No. 2................minutes per inch Depth of Test Pit..._.........._..... Depth to ground water-.-_--_____--__-..___-_-
a ........4 ---------------------***--------------*----------*------
-----------------------------------------*....... ....................."....
0 Description of Soil........... ........ ............ .•. •. . ... ..................
.................................................. ---- ....... . ..... _.];.U.�..............
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 TJITI 1Z- 5 of the State Sanitary Code—The undersigned f);�ther agrees not to place the system in
-i j to f C Ti 5Ud b y t) boar �f I eldth operation until a Certi te f Compliance bas been
r A 4
A!igned ...... ........ . .. . ..............................
/-------------------- "
Date
v ........... ..Z.e_/7_ ..........
Application ApprovePBy.............. ......�_,--_C...
Date
Application Disapproved for the following reasons:................................................................................................................
........................................................................................................................................................................................................
I Date
PermitNo.--. ............. Issued.......................................................
Date
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I M ^C&L
DATA
E _
No.4�15--.-&.a 6 FE�i . ..........e`
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
y ..
Appliration for Uispniial Works Tomtrurtiun Famit
Application is hereby made for a Permit to Construct ( 1,1 or Repair ( ) an Individual Sewage Disposal
System at:
................_................................................................................... ;. 4 ♦ t . ¢ ? 1,.q, ,- a
Location-Address or Lot No.
......................_..................•. •--•-•......•--........ ..-••--L............ ••....--•---------........................... -------------------------------------------
Owner Address
Installer Address �.+ .
UType of Building ,, Size Lot.... .': ...........I__�__Sq. feet
�. Dwelling—No. of Bedrooms_________________; ...._...._.________...Expansion Attic ( ) Garbage Grinder ( )
aOther—Type
of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
PkOther fixtures --------------•--•...........----•--•----•-•-••-••--••---••----------•-••---.....------------•----••-----•-•----•----....-
W Design Flow...................`.."......,..,.....gallons per person per day. Total daily flow.._.......__._.._.... `'. .......gallons.
WSeptic Tank—Liquid capacity ":!.Ogallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width-_..._-_............. Total Length.................... Total leaching area_.__._..____........sq. ft.
Seepage Pit No.._..,,..__�'______..p g Diameter.._.......':r _-_- Depth below inlet... `'"......... Total leaching area...'.' µ_...sq. ft.
Z Other Distribution box ( )" Dosing tank
`-� Percolation Test Results Performed by 4:�'_. " g f" + '.a :....................•___._____. Date... �` .__.;�._:_�__:��__._.
a
Test Pit No. I.... ',.:Z__-_minutes per inch W Depth of Test Pit......;.. ,.s._. Depth to ground water.....
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
D Description of Soil------------------------•- .._:.... ..... _...... ...................s _ ............
..._..
_ _
W -•••••••---•.....-••-•--------------------------------------------------•-; ...........-------•---------•-----------•-•----------------...---------------•--------------••••--•-•-----•-------••---•-
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 T ITILE 5 of the State Sanitary Code—The undersigned f .ther agrees not to place the system in
operation until a Certifi to of Compliance as been ' by tja� boar f ealtli
igned--••--•......... =r,
Date
Application Approve By------. •---- .... ...............................................
Date
Application Disapproved for the following reasons---------------•--.............-----------------------------•-----------------•------------------------..••.•-
1 .
..................................`A
-•-�•..... . ---•----........._........................•-----•------••-•••---•-........................-Dau--- ..
cam-
Permit Noa.�-?'.� �` __L1_4— Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Ir �� r.. oF........................'.A ��'' 1 `,i ....................
C9rdifirate oaf TuattpliFanre
THIS IS_T�RTIF�
T�h�t the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by.... ,�rl y�.- ..........................................................(� sca �
�J talle �_ ( '......
has been installed in accordance with the provisions of TITU 5 gff he State Sanitary Code as de•cribed in the
application for Disposal Works Construction Permit_No._d—,g....f!_.a_�__...... d-ated_.,�Z/___4 .�f,(.................
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNC ION SATISFACTORY.
DATE................ ...... .Lh�------------------------------- Inspector-----------i
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
ZX J
//Q .l'�r.1......OF.. ,. .. ............................... .................... F .3"' Gin
!'t, r
NO ...................... EE....................
0hipp at �/ork,� nnotrurt#ion amit
Permission is hereby granted---., �. ::-------•• t�Z4.4-----------------•----•-------•----------....-------••---....----.................
to Constr ct (k,' r Repair ) an Ind i idu Se wa�e,(�ispos Syst _
at No...... 4: _ ......--•--- ..--. ....A.........---
Street � L
as shown on the application for Disposal Wor s Construction Permit No...................._. ated.___1 /_• ..-.- -5--.•_--
----•------------------- � � �`------( ...
f j Board of Health
DATE:, { ••-• �Lf!
k
FORA Iz.55 HOB. & WARREN. INC., PUBLISHERS -
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