HomeMy WebLinkAbout0090 GUILDFORD ROAD - Health (2) qo (-gu I'I rd 2a
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
-._...-.._ ..._.. ._......OF
��� .� liratt.on for Disposal Works Tons r inn Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: �
D .......... e .....1. .. .... ...OPI.IM"d......./.@n/.. ...... of tvile:....................................... .................
Lo on•A ress or Lot No.
..........,�1!� ,rxae�s ..... s ............... 's� e.................................. ......
g/vner Address
9 W Tel Ies.--. CJ_!--(.Q/tiL�? ..........................LHG ...........
Installer Address
UType of Building Size Lot_./��:+�...........Sq. feet
Dwelling—No. of Bedrooms_____________ ..._...________.______Expansion Attic ( ) Garbage Grinder ( )
a
aOther—Type of Building __Gu(l�Or__ _ern& No. of persons__________4............... Showers ( ) — Cafeteria ( )
d Other fixtures
Design Flow...................... gallons per person per day. Total daily flow_..___._.___
W ���j}} P P� P Y Y �-00......................gallons.
WSeptic Tank—Liquid capacity/�_"v.__gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No.____________________ Wit ................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No-_-____ _-____ Diameter_. 0 --
� -------- -�,q� Depth below inlet____________________ Total leaching area__.3�� ...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.........................
G� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
01 -----•--•--•-••--
O Description of Soil---------------S1�11/1 __� AYe"Cj x - - - --
U -------------
•----------------------
•------------
•------------------------
•----------------------------------------------------------------------------------
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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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee ssued by the b rd of health.
Signd e..... .............................................
` Dat
Application Approved BY - -----------•--------- l �. .
----•..................•••---•••-----------------_.Date••••--
Application Disapproved for the following reasons________________________________________ ______
................................--------------------...--------•---------------•-•-----....-----------... -------------------------------------------•-----------•------•------•••-----------••-•--•-
Date
PermitNo......................................................... Issued........................................................
Date
.- ---- - -- - - --- - - --' -- - - -- --- --�--- -
No....-(Z --••-.•_... Fzz........�......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....... _................................OF .
Appliratiott for Disposal Works Tottotrortiott Vvermit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
...........:: .... .............. /9r1!rr� '.: .�j � ..........................................................
d .
&Lion Address .. ...or Lot No.
ry Owner Address
ai :�.t' Y ....sd �.'3. i{.i1 �tr�. .'...........•............... d J� ..a 3 ...+! ' ...._..4 +?b. ....._..._._......._..._....... ......._......__......
Installer Address
Q Type of Building Size Lot_/ ....__....Sq. feet
Dwelling—No. of Bedrooms... ......: ................Expansion Attic ( ) Garbage Grinder ( )
114 Other—Type of Building W...:.....__ "} No. of persons.......... •............... Showers ( ) — Cafeteria ( )
QOther fixtures --------------------•----------•---•--------------------•--•---•----•---•--•-•-•••••......--
W Design Flow...................... .�..............gallons per person per day. Total daily flow...........«a*.......................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No........:............ Width...._t;�k_ .........._ Total Length......__.__......... Total leaching area..._..............._sq. ft.
, ter; s �«
Seepage Pit No..................... Diameter.-. , _.Pt... 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.......................
--•-
O Description of Soil.......... t�`�"•_��..................................................
,�: �........................•---•---••--------•-•--•--•--.........................................................
x - -----•------------------------------------•----•-----------------....---------...................................
0 ------------------------------•----....------------------•---......----------•-•-----•--•-•-- -----•--------- ---------------•-----------------------------•......................................
------------------------=---------------------------------•-----------------•---•-------•-----•--...------•--------------...----•------ --------•----•-----------------------------------•••••••....--•-
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 been9. ssued by the board of health.
Sig dft
'
----------------------
Application Approved By..... -�l'�"�. �___ �a
Date
Application Disapproved for the following reasons:................
.....7-•--•=---•••-----•....................................•........---... •--...........
.................................................-..................................................................................................... ..................................................
Date
PermitNo......................................................... Issued.........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
9
..............................................
Tatifirate of (Somplitturr
THI,S,t IS TO CtRTrTPY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by------...t .. � ...` ---
........----------- ----•--.--.-----------
�rs o5 Ius filer ---..... f'7�
at -----•••• --- _ - --- ----- ------------------------------- --
has been installed in accordance with the provisions of Article XI of The State Sanitary Coe as descr' ed; t the
application for Disposal Works Construction Permit No................... _f_-t�_.. dated -_ __ ._.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BEZONSTRUE® AS A GUARANTEE THAT THE
SYSTEM! WILL FUNCTION SATISFACTORY. ..
DATE............................................................... :_........ Inspector..-----0,f.. .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH.
. ....... ......... ............................................
No.......................... FEE........................
Bioposal Works ifoustrurtion Prrutit
Permission is hereby granted.......
......�'�.I{' '".
....-•...........................••--•........................
to Construct ( ) or Repair ,( ) aiIndi}idual,Sewage Disposal-System
at No............ :r�° yet ...... ���t
................< ..........�......:. ....... . ..........._....... ........._Street..............................,................. :...........,�.......
as shown on the application for Disposal Works Construction e�:mit N . ..: .../_ Dated..,.:. .-
...�f
...............................
. ............................
Board of Health
DATE..... �� ---•---------------------------------------
FORM 1255 HOBBS & WARREN. .I NC.. PUBLISHERS ;