HomeMy WebLinkAbout0173 GUILDFORD ROAD - Health (2) 1�3 G�r`(��v rod �o�i-�
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/..a.W...N ........... OF....IJAR..N.S. A.2.L.C............:....................................
Appliraffint for 43isposat Works Tonstrur#inn Vami#
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
system at d l�a� d
....... .Qt....... .......................�---•-----:d........... ...... .......................---.....------------ ...--•....----.............................
\ L-ration.Address or
.........::moo m...P.r t� �►a n e s z e . /�.. l.�. > ....... aitesL��1.� ......................
.......... ................................................. ......
W J� Onpp ' 0 C . . ..... ddrrQa.
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Installer Ades U Type of Building Size Lot........r. '........Sq. feet
Dwelling—No. of Bedrooms........................................Expansion ttic ( ) Garbage Grinder ( )
a Other—Type of Building .wr�s% ...Cx !P'`No. of persons.........e.
................... Showers ( ) — Cafeteria ( )
dOther fixtures ---•---------------------•---------------------•--------...-•••••......-----•--- --------------------------------------------------------------------
W Design Flow....................: ..................gallons per person per day. Total daily flow......6 ..............................gallons.
W Septic Tank—Liquid capacity ...gallons Length................ Width................ Diameter................ Depth........._......
x Disposal Trench—No..................... Widtb.C'cFS� ......... Total Length.................... Total leaching area---------_..........sq. ft.
Seepage Pit No_____________________ Diameter--__-----jpAx-Z Depth below inlet.................... Total leaching area.-.?5!.r...sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................P P P
Test Pit No. ................mmutes per inch Depth of Test Pit_._________.___..... Depth to ground water_________.__..._....___.
f4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-------.-_______-____---
P4 .................n�-----------••..._.......••-----••--..............-••---••-•-••---
Description of Soil.-----5'� N_Y.Y.. � ---------•---•...............................
U --•---•--••••••••------•--••--•••-••••••.......-•--•-••-••••-•-----•--•••--•-•••-•----•••••••--------•----••••••----•---••-•-•----•-•--•-•-••---•-•-••-••••----...•-•--••••---••--••----••......----•---
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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 Co —The under ' ned further agrees not to place the system in
operation until a Certificate of Compliance has been ed by�i ar of health.
Si -• .....:. .... .............••....•............ ................................
D to
Application Approved By---- = G[.M ............ .. --.
/Date
Application Disapproved for the following reasons:................................................................................................................
........----••----•••...............••-•---••-------•-••-•-•---••••••----••-•-•........--••--•••---•---.....••-•••---•••-•---•••••--••---•-••--•-•••--••-------•-•••-••.................................
Date
PermitNo......................................................... Issued........................................................
Date
��.... .... --------------- --—-,-------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. --- ..............OF..../3 ----'------------ '
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for� �
Appitr« tmo�o �� Disposal WorksToWotrar4illn ranti4
Application .' `f� .
is hereby
made for u Permit to Construct ( ) po �pu�. ( ) an Individual Sewage Disposal
Svobsoat;
'
.......................... ................. .......'.....ZL'.......................... .....................________________________________________
. or L
.-Owner —Address
Installer AZess
Type o6Building Size Lot-''/ ..-'Sn feet
Dwelling—No. of Bedrooms............l----------.-..--Expansion Attic ( ) Garbage Grinder'( )
-Other—Type of uf persons--.................... Showers Cafeteria ( )
~~ <Jt6cr fixtures ---.-.-.--.----.-.--_---_-..'-..---_.-------._-----_.-_-----___--_
Design F�nv_----------------'_�aDooa per pccsuu per 6uv Total daily 8o�-.��'���............................gallons.
Septic Tank—Liquid .guUoun Length................ Width................ Diameter................ Depth................
Disposal Trench--BTu Length.................... Total leaching area...................sg. f t.
F� Seepage pit 2qu_.----.-. Diameter.' ^ Depth below idcL.---_-.-- Total leaching area_ --ml. h.
(}t6ec Distribution box ( ) D ` tank ( \
~� Percolation Test Results Performed 6y......................................................................... Dote........................................
Test Pit No. l................minutes per inch Depth of Test Pit--.-- ....... Depth to ground wutcr,--.---.--
c14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground wutcc-__.----.
0 _-_-_._ --_---''---_'---.'.-----__-'_--_---__.-_----___'--.
Description �� _������--�- -----.'-----------_--_--_-_------__---
__-_-_-_-'_---'-_.--__-----_'_---_-----_-----'--_-'-_.---.------------_-.---_
| -------.----'--''—'--'----''-------''--''-------'_--.-_-.---'-'.-'_'-.----_--__--. |
Nature of Repairs or Alterations--Answer when ---._----'_--_-----'_----------_-_- �
_-_--_-''' __------_'---_--_--.---.----.-'_--'-_-.,--_------_'---_-'-
' g,-_-__.
The undersigned agrees to install the u[orodcocribed Individual Sewage System in accordance w��
the of Article XI of the State Sanitary agrees not to place the system in
operation until a Certificate of-Compliance has beer�#S§lled by�ftp b6ara of health.
IlAte
---'--`- --------'-`---`
' , Approved By_ -__--'
'
~~`
Application Disapproved for the following reasons:---------
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--- '..._-...--'....--__.-..-'..--..---_--_---_---`_'-'---._'���---_- �
Permit No. ` � _
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THE COMMONWEALTH opwAsaAoHusszTs
BOARD OF HEA H
=^^----'^^'-�~^~~^"�"�^��`'=`--------------
Tertifirate of Toutpliattrit
THIS IS TO CERTIf, Y, That the Individual Sewage Disposal System constructed /41or Repaired
Installer
has been installed in accordance with the provisions of Article XI of The State Sanitary Co e as deFribed in the
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A UARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE �
THE comwowvvsALT* or wAssAcMussrrs
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as showPon the application fo Disposal Works Construction run o
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