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HomeMy WebLinkAbout0062 MILLSTONE WAY - Health (2) �} - psi-1�� _� ____ o No.44_ .... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ..... ............OF.... +s. 'f1 M�? 2��✓ 5� Appliration for Disposal lUvrks Tomitrurti.ou Prrutit Application is hereby made for a Permit to Construct (VI or Repair ( ) an Individual Sewage Disposal System at L©T * 9 0�/�1STo�vC G���/ �F✓UTF�-we-&E f}-s5. i� •. .• ---------... ! �1 Lo do -Address or Lot No. l�(d- ..................................... �..'e �..... ---- zees �� :� �c/: �e du T% ....------ Owner Address G /US 7 S6 G�E G� 6 T_ �lE d 5lV1,C-1— L� a / ------------ � Installer Address UType of Building Size Lot.... ...Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder (X) `-4 Other—Type of Building No. of persons_______________•_______-____ Showers — Cafeteria Q' Other fixtures W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capgaqc}}'ty�Mdgallons Length.t "6_"_. Width_-'7/1 Diameter________________ Depth_ x Disposal Trench—No. __- Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit Diameters/19."_... Depth below inlet....6.1.__..__ T tal 1 Ching area________ --------sq. ft. Z Other Distribution box ( ) Dosing tank ( % � - � a Percolation Test Results Performed by.......................................................................... Date----------------- ------------------ H 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.........-_--_-__------- Descriptionof Soil • --- -------------------------------------------------------------------------------------- x 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 Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has ben issued b t4 board of h lth. Si e _ `- � ' 7 3 Application Approved By... ------ fit ------_.-----.` Date Application Disapproved for the following reasons: -----------------------------------------------------------•--------------------------- -------••-----------------------------------------------•-------------------------------------------------------=----------------•-------•-••----------------------------------- ------- ----------- / Date Permit No. .................................. Issued -------------- D { Date No �. _ ...... Fps ` THE COMMONWEALTH OF MASSACHUSETTS R BOARD OF - HEALTH AlpliIiratio8i for Bi,ipooa1 Works Tonotrn.tion "amit :Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage ti)sposal System at: . ... J dF z} ' aLs t s1- ; . 'r r�; . 5 Location-Address Lot No. 2�.- s dam. ....� .'•- -a-< ---- �=--:-s a. r� -r _ -------- Owner r�tlddres ` r r x r b ;' I rf r y ....J i 4,,.ftrf / { = "3 :. cry —. y^^'�� •P � Installer Address Q Type of Building Size Lot__:: t _ S feet U Dwelling No. of Bedrooms....___ - J>- "Grinder.-+ g— .� ______________________________Expansion Attic � Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons_________-_________-_______ Showers ( ) — Cafeteria ( ) dOther fix tt.ires --------------------------•-•-•...----•-•-------.....___..----------••---•-----------------------•------- WDesign Flow................_...................._......gallons per person per day. Total daily flow............................................gallons` r WSeptic Tank—Liquid.capacity, ins .gallons Length _:4 Diameter__- _______ Depth .!,6"f.. x Disposal..Trench—.No.__�;_% ��r� .___ Width.................... Total Length.................... Total leaching area---...__________.___sq. ft. Seepage Pit No +?z'j t .oa._= Diameter- _fF :t_..__ 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__.__________________.-. 44 Test Pit No. 2................minutes per inch Depth,of Test Pit.................... Depth to ground water.._:_.___"_-________-._. -- O Description of Soil_____.. 1� yet p' r ,fit r e �� .l ---------------------•--------"-----•-----------------" ---------------------- U -----------•------•------------------ -------- -----•-- ......_.._---------- - •--•-•---------•--------------•-------•--•----------•---__..._....._.. •-•--•--- 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 Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Si e 4^ I"� �j �+' .p _ .. - .. f g11 `'' ,rr ,.4i.- a'?'��'' fi '#�' `�31+''ttr?J` __ _ ______________ - ,m'Dath. h .. Application Approved By er' ,& y: e �.' / rr ( " '` �" 'Dat Application Disapproved for' the following reasons----------------- •----•-------•------------••--------------------------------------------•--------------------- Date Permit No. . ----Z---=-•--••=•.......................... Issued.................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............. .....° .. ..........OF....: l"AA . ., ry>�aS� .................................. t Tntif iratr of Tontphatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed j or Repaired ( ) b r y :(r eet� Y .. — Cac �+ nstfleyr� li ' at t �g .,,�''. ............................................................... has been installed in accordance.with t e nvisions of�Article X of,rThe State Sanitary Code as described in the s application for Disposal Works Construction Permit No....... .:'" ___________________ dated................................................ ' THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTR D AS A G94RANTEE THAT THE w SYSTEM WILL FUNCTION SATJSFA,0TORY. DATE.__ -------- Inspector THE COMMONWEALTH OF MASSACHUSETTS BOARD'- OF HEALTH .> 0 �. tea:-------------------------- No.....- - FEE �i��o��t� �ar�,� Cnon�#rnxtiolt : �rntif Permission is hereby granted f ev E to Construct' ) or Repair ( ) an ildividual Sewage Dtsposa Syste .at No .ter- + == �,y ` . j �r �* ,v ' ` <Y$ r'Str et i -----A j4yr= :as shown on the application for Disposal Works Construction Permit No.-,,-; V:-- Dated _ { - ------------ : BoarLof Health DATE.................................... , FORM 1255 'H"OBBS.,& WARREN. INC.. PUBLISHERS` n.�fi h`✓� �\