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Home My WebLink About0170 GUILDFORD ROAD - Health (2) i No...... ......_.` Fxx.. l d .................... THE COMMONWEALTH OF MASSACH•�U-SETTS BOARD OF HEAL. 1 OF....... ---............................................. Appliraiion for i-4vanl 19orkg (9nnstrlitrtiun 1hrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: * �-4t) Location- ddr s or Lot N ............_............d.... ..................... .yyy ................... .......................... ...... ............................. ...... Owner Ad a ............................ . ... ............. ... ..................... .. ............. ... ................................................. Instal r Address Q Type of Buil g Size Lot.......,v .Sq. feet .- Dwelling—No. of Bedrooms...... ..... .............................Expansion Atti ( ) Garbage Grinder ( ) aOther —Type of Building No. of persons............... ........ Showers ( ) — Cafeteria ( ) dOther fixtures .................. --••-•-•--••.....................••••---•--•-•-•••...--•------------•-••••-•-----•--•--••--•••----•---•--•--•--••-••--•-••----•-- W Design Flow.................v d............. .gallons per person per day. Total daily flow......... _............_..........gallons. WSeptic Tank—Liquid capacity/gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Widt. --_- ----.--.---- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.. _____ epth below inlet.................... Total leaching area..�d.f ..sq. ft. Z Other Distribution box ( ) Do g tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water_____-___-_-___-__,___-. V-4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ --•••• •--•-------•-•••--••------------------------------------- O Description of Soil...... ....... ......A U -•-•-•---•--••---•--••---•••---•-----•---••••••--••••---------•----•--••--•••----•-------------------•------------------------------------•----•-----------------------•---••.......--------••--••--•-. 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 aI of the State Sanitary Code The undersign further agrees not to place the system in operation until a Certificate of Compliance has been ' by theApargYof geal Signe -.......... ----- ------------ Dat Application Approved By......... � ate Application Disapproved for the following reasons:........................................... ................................................................... -----------•-•-••--•••-•-•--•----•--•-•--•-----------------•----•--......•••----•----•••--•••--•-------------------•--•---------•-•-•----••••-••--•-----------•••--••---••............----•-----•----•- Date PermitNo......................................................... Issued........................................................ Date No......................... Fs$..., ...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH °' ' ._......OF........Yf Appliratiuu fur Bispouaf 10orkii Toasts ion Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage.Disposal System at, 1✓ Pj ,`%� j ............... . s r�f�! ;,r ... .. ........... ....................................................... anon ddr sy a - # -�l/or Lot O caner . /ti p Add j p .. a .ate a ......... ............. ........ Install r Address U :i;9L Type of BullSize Lot-__-., „ _.. ........_. q. feet Dwelling—No. of Bedrooms._.... .._.j.............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building __'. _: 1._ = No. of persons................ ........ Showers ( ) — Cafeteria ( ) dOther fixtures --•--•---•-•--••-- ---•----•--------••--•---•---•--.....---••-•.....................•-----••--••--••---•.......................................... W Design Flow................................. gallons gallons per person per day. Total daily flow-__-__---- 1`.0...-..... gallons. WSeptic Tank—Liquid capacitya -09"allons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.._......... ...... Total Length.................... Total leaching area.............._._.._sq. ft. Seepage Pit No..................... Diameter.r _K,,�!f epth below inlet.................... Total leaching area.::at..I�n..sq. ft. Z Other Distribution box ( ) DoO g tank ( ) `-, Percolation Test Results Performed by......................................................................... Date........................................ 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_-_---____--_________--. O Description of Soil-- ' , - . _ - - - V -----------•--•-•------------------ -----...--•---------......----•------------.....----------- -----...-----------------•--------------------•------------------------•--.....--•------•---- W UNature 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 Cod�e The undersign further agrees not to place the system in operation until a Certificate of Compliance has been} fi l by the spar . of health. r, Slgne .,� ^? ......._ ......... I. 4 ............ }� } 1 V . ... .. Application Approved BY....... , �":. s= 1 ...... ,.. �2.Aa. Application Disapproved for the following reasons:............................................ ... ..................................................ate ` ................................................................................................................................................................ ------------------.........----------- Date' PermitNo......................................................... Issued.-•-................................................... Date HE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT y .......................................................... (9rdifiratr of (to ua fiaturr THIS IS lI CERTIFY, tIndlvldua#1 Sewage Disposal System constructed ( ) or Repaired ( ) f ----nst it r at...............................^ df ...__. ....... ? ?. has been installed in accordance with the provisiox of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......__.4,4�V____________________ dated ..��.1.1;.4. ---- , _.___........ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. f)DATE.................. -1-�-.--lZ- ......................... Inspector----------------!...v............----.. ......- .. ,THE COMMONWEALTH OF.MASSACHUSETTS BOARD,, HEALTH, Q�iF No..... _.... FEE--- ............... %p.osca1 � rk (fo it ion Prruait f Permission is hereby granted..........ram' , r: ,,....., ��..._..... to Construct ( ) or. a air ( n Iv Se ge posal stem t . at No....... . � � � � '` ................... !/� . ,_ 6................. ..... Street.. as shown on the application for Disposal Work Construction Per i No....(s . �.... Dated........Z- ._..� ,73 ................... ........ ya............... /` � Board of Hcalth i DATE -t:.:..... FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS