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Home My WebLink About0330 OLD STAGE ROAD - Health (2) 6 / /Os r , No.....7/Orl ....... :. I+�s... :.4✓.. ....... THE COMMONWEALTH OF MASSACHUSETTS _ BOAR® OF HEALTH 11os Jos Applira#ian for Bispaml Works Tun rn.rtiun jiumit Application is hereby made for a Permit to Construct ( ) or Repair (1-1 an Individual Sewage Disposal System at: ...... 3. ..._ :�. :... = .. -------------- ---------------------------------------------------------------•-------........................._. Location•A dress /� or Lot No. ...... L .................................................... W — caner �, Address W �?i:. a- !��C� C,?Y� .7 .. �.ff S11-------------------------------------------------- Installer Address Type of Building Size Lot............................Sq. feet 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................ 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 ( ) 1.4 Percolation 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........................ ----- - -•••---c& --------------------------------------------------------------------------------------------- Description of Soil_.__..__... b� _ . �� _ -•----•------------------•-•-•----•-------._...._...-•----•-•--•----- U ---•-•-•••••......................•••-------••------•---------------------.._...---•-----------•-••---•---------•---•••----.-_._-----•-•--•----•--------•--...------........------------••------------•- W U Nature of Repairs or Alterations—Answer when applicable__._j_"'d_()C_)C}.:_ ,_� '�_ _ j_ . �_________________________ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iI:E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has en ssued by theAoar o health. �Cd�-dam VSigned..- ..---��---•---- ------=-----------------------•-----------•--.......--•-Application Approved By---•• /.'.��-------------------•--------•-•-l/ D Date Application Disapproved for the following reasons:.............................................................................................................. ••----•-•-----------------------------------•-----....-----------............----._......._..----...._..---•...-•••-____--•-........................................................................... Date Permit No........._.�.�.7................................ 1 Issued_ .... � Date No...... 2:7....... Fps.. . ..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r Appliration for Dispas al .arks Tnnitrnrtion rranit Applicaho'fi is hereby made for a. Permit to Construct ( ) or Repair (4-ol an Individual Sewage Disposal System at: ----- -------- •---.._ ..-------...........--- Location- ddress or Lot No. caner " Address Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons. Showers a YP g ------•-•----•-•------------ P - (---->--- Cafeteria ( ) dOther 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........................................ Test Pit No. I................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------• - � raise k -•-•••--••------•••-----•••----•••-......•••-------•-----•---•--•......•................ x c, w UNature of Repairs or Alterations—Answer when applicable " ° l ad I 1 rA ........................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sta itar Code—The undersigned further agrees not to lace the system in �} Y ..� g g P Y action until a Certificate of Compliances ha een issued by the Hoar f health ope>r, � � ,mod Signed '_ :....� _ ........ -• ----- •-------------•--•--- - �--•- s +.... DaEe' Application Approved BY-----�}'-------•--•--- •---------------------•--•--...---....._..------ Date Application Disapproved for the following reasons----------------•--------......------------------------------.........----------•-•--•••-•-•-------•........... ............... .......•----•--•._.... ..-••-••--- - - Date ---- Permit No...... ... Issue(.- j 7 Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HkALTH ....,.:. . .C :......OF........ a� ,......4................. +! �Y Sy rt:), Tntifiratr of ToutpliFanrr A T F; S IS TO CERTIFY, That the I (1-efl.iduaI Se z e Disposal SysteV.m constructed ( ) or Repaired b ----------------------------- g �V y It 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 C STRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......... - . -----------(-•--•................................•-- Inspector-----------•• _ ------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF 4HEALTTI : laisvo l nrka TianVitriion rranPermissionis hereby granted__. ...::_ . : " _ [)9 `3 - - to Cong uct ( ) or R ai.' an Individual Swage Disposal, stem - at No.. -_--CIQL..� _...�1 .... _ .� ------------------- °. .. Street i as shown on the applic4,16n`for Disposal Works Construction Permit No...... Dated........�!r�'�'�.............. - 1 ......................................... . .................................. +? DATE.... j 6 ... ..__:.... Board of Heal; FORM 1255 HOBBS & WARREN. INC., PUBLISHERS '`