HomeMy WebLinkAbout0088 FIVE CORNERS ROAD - Health (2) vd(-e
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
--
------------OF...................................... ---------------....
Application for Disposal Vorkg Tonstrurtion Pumit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
ff -------------- ---•- ---- --------
Location-A&e or Lot No.
�..t...I----------------- •---•--------•-•••-•••••-•••••......•-----------•---
W Owner/ Address
Installer Address
d Type of Building Size Lot............................Sq. feet.
U Dwelling—No. of Bedrooms._........................... .........Expansion Attic ( ) Garbage Grinder ( )
P`-4-, Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Pa Other fi tures ....................•--••••••-
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----------------------------------------
,� 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____________________._..
W -••••--•••••----••----------•---•••••------•----••-•----•••-•••••••----------•-••••--•--••-•----•............................................................
0 Description of Soil........................................................................................................................................................................
W
-------------------------------------------------------------------------------------••---------------------------------------------------------------------------- ................................
UNature of Repairs or Alterations—Answer when applicable._____________________________________________________________________________________---------
---------------------------------- ------. -=•----------------------------------------------------------
Agreement: l/
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 iss the b rd of heal
Signed .•---- • --••- .... ••• . ...... -`-�-----J -.7S------- `
'� Date
Application Approved �= -�3
Date
Application Disapproved for the following reasons:..................................................................I----------------------------------------------
---------------------------------------------------------------------------------------------------------I-----------------------------------------------------------------------------------------------
Date
PermitNo.......3j..j .................................. Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OR HEALTH
------........_.. .....-..- .............OF...........
...................- ....
Appli.eation for 1iopnoal Worko Tonitrurtintt thrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
---------=..-- -- �-.J........�'6°....--- .... :------•------ ------•--•---- - gyp °�d/ :-4 sn............................................
Location-Acres
or Lot No.
Owner Address
FW„1 ...--------------------------•----..... -------•--•==_- '"�'=----- :..-----•.............. ............................•.....................................................................
Installer Address
UType of Building Size Lot---------------------------Sq. feet
Dwelling—No. of Bedrooms._:°___- :...........................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ---•-----------•--------------------•----•-----------
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----------------------------------------
Test Pit,No. 1................minutes per inch Depth of Test Pit------..-__---_--___ Depth to ground water-*. ...............
(q -Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water___.•..____-______.____.
0 I ------•----------•--------------------------•------•---------------•----------••-------.......------------...-------•----------------•-•--•-•----••---------
Description of Soil........................................................................................................................................................................
U ;r.A A-41---------------------------------------------------------------------------------- -----------------------------•-------------------
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 undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss the b ord of health .;j
z1
Signed._. . .__ '' .o. t = ° ac:c. ` •* ~ ?
I Date
Application Approved B. s ...- ' . � } r ... 7.3
�:
Date
Application Disapproved for the following reasons:................................................................................................................
-..............................------•-•--
Date
PermitNo......... _. - -------------------------•-------- Is sued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS f j !'�G _ J.A
BOARD OF HEALTH
�.6C..........OF........ .....................................
Tntif iratle of TWIntpliattre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
.aw Installer
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.___._b __ _ _______________________ dated..__....Y ' _ _._._._______.._.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE �� �--/--�---� ------------------•--•----- RInspector----------- ....... r�5 (•------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......................................... ................................ 61 .
No.............:.......... FEE.........................
Bgglagat arkii (TArtitrttrtion erutit
Permission .is hereby granted-- �.-------- 1--_ m l= ' ----•--------------------------------------•---••••--
to Construct ( or Repair ()()'an Individual Swage Disposal System
at No.............
~# t `tj/ 11 Gs
Street
as shown on the application for Disposal Works Construction Permit No 317... Dated_..._ "`--'' =. d.....
' . .
x = ---
DATE. � 1 3 Board OffI.calth
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FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS