HomeMy WebLinkAbout0094 BIRCHILL ROAD - Health (2) IFs�I'0Z/
No.._..... ....... I.....................
THE COMMONWEALTH OF MASSACHUSETTS
1 � �Z� BOARD F HEAL H
' rj,, AA^^. ..... .......:....OF.......A .. ... ..... .R_2
Applirutiun -fur Uiupuuttl Workii Tonutrurtion Prrmit
Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Sys
--...--•---. -V ------------------ ------•-•----•-•-•-------------••......••------- • • .........................
cation-Address or Lot No.
Z,_ 4 ..
wneyr� , Address
Installer Address
UType of Building Size Lot-_-------------------------Sq. feet
.� Dwelling No. of Bedrooms........................................:...Expansion Attic ( ) Garbage Grinder ( )
per, Other—Type of Building -__________________________ No. of persons.--_____-----__-_•-----_-- Showers ( ) — Cafeteria ( )
0.' Other 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 ('. )
aPercolation Test Results Performed by------- --------- ------------------------------------------------------- Date------------------------- -------------
a Test Pit No. 1----------------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------ .. ......
-
x
U ------------------------------------------------ ...................................................------------------------------------------------------------------------- --------------------
x ------------- ---------------- ---------------------------------- ------------------------- _ ----------------------------------
V Nat r of Re irs. Alterations swer when applicable...___/. ___-'_/00_0__.._•-_�� �2-6Q-� 1---=--_-__
..�.�uJ------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State Sanitary Code— The undersigned further agrees not to place the system in _
operation until a Certificate of Compliance has b is ued by the bo rd o he lth.
Signe = � V-44-aft"_ ��/
Dat
Application Approved B
Date
Application Disapproved for the following reasons--------------------------- -------------------------------------------------------------------------=------
..........................--------------------------------------------------------------------------------------------------------------------------------------•--------••••----------------
Date
Permit No......................................................... Issued`..... - -2---'1`
- ---------------------------------
Date
No............. ---------- Fss..............................
THE COMMONWEALTH OF MASSACHUSETTS
y ARD OF, HEALT
7
��
� BO �OF...... ..................
Application -for Disposal Works Cnonstrurtion Vamit
Application is .he eby'made for a Permit to Construct ( ) or Repair ( �n Individual Sewage Disposal
System a
•-f Y.-------------- ....... ------------ -- .................................................... ------------------------------------
..
Lo tion ddress or Lot No.
caner �� Address
W V ------ r a
� Installer Address
Uype of Building Size Lot----------------------------Sq. feet
Dwelling lKo. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ..............."._.___._____ No. of persons...........----------------- Showers ( ' ) — Cafeteria ( )
QI r ;
d Oth& fixtures --------------------------------------------------------------------
W
Design Flow------------______________y{r --_.gallons per pet-son per day. Total daily flow------------------------------------------._gallons.
WSeptic "1 tnk—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 ( )
aPercolation Test Resultsrp Performed bY-------------------------------------------------------------------------- Date--------"---------------------.•-.-----
Test Pit N,o. I A:- :_____..."minutes per inch Depth of Test Pit_.--"_______________ Depth to ground water...-_".-_--_..__.__--
. ,<
GZA Test Pit=-No. 2_______________minutes per !inch Depth of Test Pit--_"-_"--______-_.._ Depth to ground
t�
water.-.-_".-_---_.-___..
----- -• -------------
.__
_O Description of Soil_; IF` e
--------------------------------- -- ---=--------------------------tU - -
----- --------- ---------------
, .:
U Natur o Repairs or Alteratio A er when applicable._--- C "eQ6------- c------
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.
3
Sign ��= 1 +"t ••-•• � �c %v� , G" 7
�! - ,
i Date
yAphcaton Approved BY / LIL . .---------------•--•---- ... -"`_/ � .
Date
Apglication.:Disapproved.for the following reasons:-----_----- -- ------------------------------------------------------------------------------------------
-
r
..........:....................•-----Z..............................---•---•--------------------------------------------------------------------------------------------------------------------------
(/� l / Date
Permit No. ........................ = --------- -- -------. Issued------�aG-=....
a. -------------------
f ..
r
5„a-
�- THE COMMONWEALTHAOF MASSACHUSETTS
AT
BOARD OFf HEAL
-
............OF.... V d
Tntif irate of f Tom-p aurr 4
T IS IS T CE T That the ' nd>vidual wage Dih offal System constructed (I, ,) or Repaired
by �'�' --•-------•------------ -------- -- - .......................
s alien
G f
at...----..•. ._-- - ------- - ........... ---- •--------------•--•-
hzs been installed in accordance with the provi ions of : X of he State Sanitary Cf�de as described in the
application for Disposal Works Construction Permit No--------------XL-of
~._._._..._... dated..__0_"o;/_.77____________.__
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THATITHE
SYSTEM WI L FUNCTION SATISFACTORY.
_._.. ' :2 `.. Insp'ector - ----------------------
DATE
THE`COMMONWEALTH OF MASSACHUSETTS
BOARD qF HEA TH
14 tj '. .......�� ............_.OF_...../ � � f��; �' ...........................
No......................... FEE- ........
Binvo I lugr s &n litho Vrr 't
Permission is hereby granted--- -- -•- - ---- ...... 74......
to Construct (.,$)I or.Rep r In vHu'al S a e osa ystem
atNo.... ! { -�-------- ---- ------------------------------------------- -------------------------------
Street
as shown on the application for Disposal Works Construction Per o.___. aated__.___._."�a/~ 7 7
-------------
` ----- _'----- +........................
Board of HealthtVl7��
DATE
VVV °
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS -