HomeMy WebLinkAbout0308 OLD STAGE ROAD - Health (2) Dld S404k
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
c -G -------oF...... C201.1.. ;
Apphratinn for :41-4puiittt Workii Tomi#rurtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair(�) an Individual Sewage Disposal
System at
- - �.................•-•.•. ---• - - .....................................
t Lola on_Address or Lot No.
�r---j5s�-- •----••--------------•-----------•--------•---------
• ner Address
Installer Address
UType of Building Size Lot----------------------------Sq. feet
Dwelling—No. of Bedrooms._-----------------------------------------Expansion Attic ( ) Garbage Grinder ( )
per, Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
0.' 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 ( )
aPercolation Test Results Performed by----------------------------------------------------•---- -------••------ Date---------------------------------------
a Test Pit No. 1................minutes per inch Depth of "Pest Pit.................... Depth to ground water-..-----.----.---.----..
r=, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-_.....--_---. ----.----
a -------------------------------------------•••----•--•---------•------•-------------'.....................................................................
0 Description of Soil....................................................................................................................................... ----------------------------
U ------------- ---------------------------------------------------------------------------•----------._-_--------------------------------------------------------------------------------------------
W ------------ ------------------------- .-.------------- -------;---------------------------------- -----------___------ - --- -/--�------- - --
U Nat e of Repairs or Alterati ns z--Answer when applicable.-- f _-_i.Q �..
-_ ; _ -- .-•--------------------------------------•----------------•-----------------------
greement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance w t
the provisions of Article aI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b issued t boar of heal
Signed.— �-��--- ' o� -' 1' �_
/Date
Application Approved B - --..�-- ---- -- - --------------��.-- -------------- -------- -----/---�--�------ - J
PP PP Y---------... � ...
Date
Application Disapproved for the following reasons--------------------------------
----------------------------------------------------------•-.....................................................
--•--•••----•------------------•-------....-- ---•----------•--._._._..---------•••-••-•--
TT //�� ate
Permit No......................................................... Issued....... ..?_-Gl.----
Date
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No..- ............ Fala.... ....�..r.�.........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Applirtt#ion -for IN-Apuiittl Workii. Towitrur#ion Pprutit
Application"is hereby made for a Permit to Construct ( ) or Repair O an Individual Sewage Disposal
System at:
o ---------------------- ---- �-------------------------------------
l
'Loc +atfon-Address or Lot No.
- _'m. ..•----•..------•---•-. ----•-•------------------------
n, ..� Address
1_791�. ................. ._/------
Installer Address
UType of Building P "'. Size Lot___________________________Sq. feet
�-, Dwelling—No. of Bedrooms----------------------------------------_----Expansion Attic' (, ) Garbage Grinder ( )
per, Other—Type a of,�Building ___________________________ No. of persons--_______________________.__,Showers ('" ') — Cafeteria ( )
Other fixtures .,. a
W Design Flow................. _..__.___:___.______gallons per person per day. Total daily flow .___ gallons.
WSeptic Tank—Liquid capacity-----------gallons Length ______________ Width- Dla-meter ".' ._._.._ Depth--`-_____-_-
x Disposal Trench—No ;.._.___.___-Width___ _____________ Total Length_________ _________ Totahleaching area_-__-______- -_____sq. ft.
-
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area-____-_-__-..__-__sq. ft.
Z Other Distribution box ( ) ' r Dosing tank ( )
aPercolation Test Results Performed by-:---- - '-----------------------------------•--------------•--•-••-•-- Date----------------I---------------_----
Test Pit No. 1................mmutes,l er�;lnch. Depth of Test` ,Pit Depth to ground water------------------------
(� Test Pit No. 2................minutes per inch Depth of Te"t`Pit_____. ------------ Depth to ground water__-___.--_..________._.
Pd .
D Description of Soil...........................................
- --- ----------------------
V ---------------------------------------------------------------------:'--------
_.,.: , . u. --------------------------------
-------------------------- ----------- --------- ----------------------------------- ------------ ` - -- - ------- -
U Nat e of Repairs or 1 erati ns— n wer when applicable -----
_ .. -ODb-
-- - ---------{---
- V -----------------------------
greement:> ..`
The'undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State,Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b issued e boar of heal
.Sbne .-- -- -------- - - - .------
D ate �.
Application Approved;B e-_ ...a. - .-.,)
Date
Application Disapproved for the,following reasons___________________
........................ ................................. --
Date
PermitNo--------------------------------- -----------=----=------- Issued..............
Date
THE COMMONWEALTH OF-MASSACHUSETTS
BOARD, PA HEALTH
i
' Tpx#ifirate of (tompliaur.r
TH}�IS TO RTIF !�}}�T��hat��th Individ Sewage Disposal System constructed ( ) or Repaired ( )
by- ..i ems• ------ .'-------L "+ ' •• - - -- -- -------------- ---------- -- -- ----- --------_ ---------
Installer- I
at -r'" i._._�f�*l -.. .a. *!+7!!:ll�r ...................
has been installed in accordance with the provtsions of Art I f he State Sanitary Code as described in the
application for Disposal Works Construction Permit No._ ..-•--•-••---_ d- ----------------------------------
THE
SYSTEM WILL FUNCTION SATISFACTORY. `
DATE---------------•----------------------•=------------------••------••---------•.. Inspector----------------------•-•------------------•----- ------------•------------......._
THE COMMONWEALTH OF MASSACHUSETTSq<„
BOARD OF HEALTH
OF
........................
N FEE
1.
Permission is hereby grante - ---------------- -----_-------------------___-__-----------------------------------------------=_-'---------_--------
to Constr ( ) r Repair •( ) an Indiv dual e e Pis s S stem��
.. � "�-sus. _a. _' f, ........... 1
s ,
treet _ /
as shown on the application for Disposal Works Construction er i o_j_�": ____ Dated_......! _ =fr`f-�;�"-___
' Board o Health
DATE--- •�
•-- -------••-•--•-•-•_... t
FORM 1255 HOBBS & WARREN.. INC., PUBLISHERS -
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