HomeMy WebLinkAbout0025 JOYCE ANNE ROAD - Health (2) "RS J a u, "Im 'dl , Land
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
------- ....OF.........................................................................................
ApplirFation for Uiipoii al Works C 15trartion ramit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
Sy st at:
�c.... .. GtL ...
dre ----'-.-------- --•--------•------------
cation r Lot No.
Owne Address
W
,.� -------------- ....._._..._ ---------------••-----------------
----'••---••-"---•--'•-•--•----•-•------•"-----------._.. _..------------------......-•----
Installer 4-...--- Address
d Type of Building Size Lot........... ............Sq. feet
aDwelling—No. of Bedrooms...__________________________________Expansion Attic ( ) Garbage Grinder ( )
p., Other—Type of Building ............................ No. of persons...........----------------- Showers ( ) — Cafeteria ( )
a' Other fixtures __________________________________
W Design Flow.....�_60........................gallons per person per day. Total daily flow____._.......:.......................gallons.
WSeptic Tank—Liquid capacity_.?..M..gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length----------
- ...._... Total leaching area....................sq. ft.
Seepage Pit No._..::._.I----------- Diameter........P...... Depth belo inl . T . Total leaching area..2.0.1....sq. ft.
Z Other Distribution box ( ✓) Dosing ank ( ) —'—' Percolation Test Results Performed by.. _ ----- .... Date......
11-. .._7 ..........
aTest Pit No. L.. .__2--._-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........................
a ------y-- ---- r•-•-•.• -�a- ----------- .............--
ODescription of Soil------•. .......!7!-.... .
x
W •-•--•-----•--------- ------------------------------------ -------------------------------------•------•-•-••-.......................................................................................
UNature of Repairs or Alterations—Answer when applicable............................................................................................... i
------••-•---••---------------•••---•------------•--•-•••-•-•••-•--••••-•---•--•-•----•-•••----••---•-•-•••-•-•••-••••------•------------•----------.........•---••••--••••-•-••-•----....-•-.......••--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITIL- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i ued by the board of health.
Sig ...................... ................................
0
Da
Application Approved By........
ate
Application Disapproved for the following reasons:..........................•.--.__._____...-_-.--------..---..__....-----------._.._....._.._.._...__.________..
--•--•-•-••-•---------------------•----------------------------------------------._._........•---- . . ...............................................................
Permit No. ..•... - .-•---
--•...........................•----•--.....----------.. Issued.-•-. t'
Date
,
-
-r
^' �
No /001 . FoB-11 .' .....
'
' THE COMMONWEALTH FmAssAo*ussrTS |
������ ���� ���� HEALTH
BOARD'' '-_ -- ' ' --' --- ' ' '
_- ................................OF---------'--
[ ` '
for
'-� ' ml Works nstrurtion -
amit
' Application is hereby made for u Permit to Construct ( A+)'eor Renuir ( ) an Individual Sewage Disposal
System at:
-
-------------------------------------------------------------
i 65!ri?._ .........
Qwne Address
-- Installer Address
Type of Buildin ` Sizefeet ]
Dwelling--No. of Bedr000m_-%.V..................................Expansion Attic ( ) " Garbage Grinder ( )
�� _Other—Type _ ' . ' ' .
/ D�e 6�t��� -_
~� .^ -.-.-- -------._-_-_-_--'-_--.---..
Disposal Trench—No- -_---------------- Width... ....... Total Length ... Total leaching area sq ft
Percolation Test Results Performed
by
���
/ ^ �
' Test Pit No. inch Depth of Test
�- `
--------------------------------------------------
._'-_---_--_---����.---_'__-.--'-__-.-_....................................................................
............
------------
.
'- Nature of Repairs or Alterations-_Answer when ---.--._--'_-.-_-_-.--.--._-_--_--_-..
............................................... -�_-'-----_----___.-_--------_______
'x Agreement:
The underagrees- to install_ the -_-----__-- Individual Sewage_ Disposal_ System in accordance� with '
' ovisions ofIIIIZ 5 of the State Sanitqjy,Code—The undersigned further agrees not to phi&'the system in
oou/ ��o�x�re oo �ooguou�a uua u�eo .
,
. Si
Awl .
^~pp~^-.-' '''p'-'-- -v-'-. �----~r-=-=-°----~-~-^-~~ /at-^ -^�--
for rxoxomx' ^' � '
Application~ ~ ~^��,. ~`~~ ' /~^~~^''/ '----'''----''�+-------'--'--------------'------''------- |
~ 1
__-__-_-'___--_...-...........����----�----____--------_--_-------_-__-----__-----.-'_'-__--
, oat"
Permit
- Date .
THE COMMONWEALTH OF wAssAonussrrs .
� BOARD Of HEALTH
.
&�
---.� . ��F�.-- ...............................................
Tntifiratr of
'___ 4 ~or Repaired
THI,W-;S TOICERTIFY, That t.h.e Individual Sewage Disposal System constructed (
er
has been fn�talled in accordance with the provisions of T 5o he State Sanitary-Co dYcribed in the
application for Disposal Works Construction Permit"No.- !Y7........ dated- ..............
THE ISSUANCE OF THIS ~~~.~. .~A.~ ~.�.~~ .~_~ ~~ -~.~~.~~~~ AS ~. GUARANTEE~ ~ THAT THE
WILL FUNCTION .'
DATE -. Inspector. . `
-'
' . THE oowwowxv1�m+o'* OF mAssACxusErrs
�
/ BOARD HEALTH
--��' .........OF'�- ..........................................
as shown on the application for Disposal Works Construction Per * No._ at d....... . ... ........................
- ..........Board Pf Health
......
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
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