HomeMy WebLinkAbout0145 OLD POST ROAD (CENT.) - Health (2) ao - ���
THE COMMONWEALTH.OF MASSACHUSETTS
BOAR® OF HEALTH
Appliration for %pos al Works Tonstrnrtiun ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at: \
.... -. ...•....... . ...........
- ......................
................_ Location-Address
--..-.---_ ..� -------- �� ......... .................
ner ' Address
a Installer / Address
Type of Building / Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
04 Other fixtures ------------------•-----
.< ------------------------------------------------------------------------------------------•-----------
W Design Flow............................................gallons per person per day. Total daily flow......................._..............•.....gallons.
WSeptic Tank—Liquid'capacity......._....gallons Length.:..............Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.....................Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ,( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................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............. . )2 _ r�rl-E) --- -- - - ------ --
U Nature of Repairs or Alterations—Answer when applicable._--_-_.- .:1�e,�)__pi' -_._. __ _ _.
1 ...................
Agreement: ,.
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL U 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has een issued by the board of health.
Signed.._.:...0 �r = 11�L�----------•- ....
1 Date
ApplicationApproved By--•--•••-••--•--••--•-•-•-••-•---•--•-.._..•--••-•---•--•••--•-••---••--••....................•-- ........................................
Date
Application Disapproved for the following reasons--------------------------------------------------------------•--------------------------•••--•••................
............................................................................•-•-•--•------------.......--••---•------••----•------••------•-•-•-•....--------- -•---
Date
PermitNo......................................................... Issued_.. ........... .................:.......
Date
No ....�.s�..
w .. .. ._
THE COMMONWEALTH OF MASSACHUSETTS Fxa
BOARD OF -HEALTH
................ 1-_:cj oF...k�:...�.-.��.' -lt_- Jul
Appliration for Diopo, al Works Tonotrnrtivit ramit
Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal
System at:
t _ ,
..................... --------------------------------------------------------------------------------------------------
Location-Address ( or Lot(No.
................I2)f?)_1Q.'12.ray............................................... ............
�...�...:.f -'= =c:: /c . ......._....................
caner Address
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms................................._..........Expansion Attic ( ) Garbage Grinder ( )
'4 Other—T e 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 capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
1.4
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a -------------!
Description of Soil............ =_ c ��=1..f.� I f t/�C {
x
I. ...........................•-•--•----•--••••••-••-••--•-•••-----••--•....._.......---•-•-••-'•......•-••'........--------
w
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 T I T I E 5 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.
Signed......................... -�:.: 1 ,,. y
Date
ApplicationApproved By.................................................................................................. ........................................
Date
Application Disapproved for the following reasons:---•-•••...-•••----------•---•--•-•---•-•-----------•'-•--••---•'--------•-------'•---•-'....••-"-----'---•-•--
...............................•----•--'--•-•••••---••••-'-•..._.....'-'•-----......_.........""'-----.---••••--_......._....•--•--•--....•----"••'•............-'••-•••••.....••--•---••-.....------
/ Date
Permit No......................................................... Issued_./l•-���=- ----------•--•-
... ......
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........I......� �!"'LF'f l....OF.......�-. !l r.l � �� �j��
..... .............................
TrrtifiraU of Tomplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (z,,)
by.............. ;-' Jt i� } r le r�y- r� �1 /_/lC_.....
-•-- -•••.....-----•----•-------- ------. -- - -
1t�.Installer
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No----------------------------------------- dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A RANTEE THAT THE
SYSTEM WILL FUNCTION SATI ACTORY.
DATE............
-... . .... Inspector ---- ----------- --- --- --------------------z.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No.....................•... FEE........................
Disposal Works Tonotru Lion rrntit_
Permission is hereby granted_._.._.... �..)C/I P l)) j ==l /)l..............................................- <
to Const uct („ ) or R air, (,X an Individual Sewage.Disp sal System_.
at No. ..•"--' . ...�-.t' I -___ ��.r'J_F� /1/�`t'l1/-//•.. . --f .l�...._J
---------- -----•--- /
� Street
as shown on the application for Disposal Works Constructions Permit .J���... Dated..........................................
�. v'
Board of Hea
DATE..........................................................................•----
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS