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Home My WebLink About0650 OLD STAGE ROAD - Health (2) lo5000 3, 41jk 01 , &ti4-, No........... ............�....... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH `re 14 ...............,.......... .......... ..... ... ........ ... .� Iir�t#ila� f tu �alrk Cn #xr#uanPermit Application is hereby made fors Permit"to "Constr uet`( ) or' Repair (/�an Individual Sewage Disposal System at .... 4y �[Ay' .. .:.. •-• ............................ Location-A ,^ , / or Lot No. 11Y � AA— ......................_ •-- ------•--•....---... ........... ....... ......... ............... ..._.__.._....----^•---•-.... wn rE ,� 1 -. -Address Installer;"° Address d Type of Building ~. Size Lot............................Sq. feet Dwelling—No. of Bedrooms --------------------- ....................Expansion, Attic ( ) Garbage Grinder ( ) N Other—Type of Buildi g `'........................... No. of persons........ ------- Showers ( ) — Cafeteria ( ) dOther fixtures .r •-•-- 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 ( ).,a Dosing tank ( ) Percolation Test Results :: y'Performed by.......................................................................... Date........................................ Test Pit No. 1......... .....!ninutes 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......................... P' :... . ,...�.�..�...�.}. .................................••---•---•--••-•-......................................................... Description of Soil__.___.... _ ____ _______ ____ez`''�'-"E: x U ............................................... _ _ ................................................................................. ......................................................................................................................................... V Nature of Repairs or Alterations—Answer when applicable_.....5�.��1a _____ ----- -------------------------------------- ...........................................:.::.:....................................:.................................................................................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT 5 of the State Sanitary — The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b en i d by thenar.. o health. - Signed . .. 1 11. Date Application Approved By---••----------------------------------------------------------------........................... ........................ ................ Date Application Disapproved for the following reasons:-----••------------------------•---------------------------------------------....---•••......•----..._......._ --------------------------•••••-•••------•--•--•-••------.............................................................................................................................................. Date Permit No.... Issued. �-•-••---•-----:...7..................... bate v t F df- 4 No.......... .. FEs..........A10. ... THE COMMONWEALTH OF MASSACHUSETTS ' BOARD OF HEALTH `..................OF...... .. .... ...: ..... :. Appliration for Disposal Works C��t�tratr� tt��Rtt" Frllttt," Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal system .... ............................................................. Location A " .. ........ .. :.. ... ........ -•-•--......• ............................................................. or Lot No. ....... ........ _..._ w e Address •- ...� . .. . Installer Address e of Building Size Lot_,.............. Sq. feet Dwelling—No. of Bedrooms .< 5 ................Expansion Attic ( ) Garbage Grinder ( ) 04 Other-Type�of.Building f....... JTo. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other'fixtures` .---------•-•-••--•---• --•---•-••-•-•----• ...-•--------------•---•-•-•-•-------------------•--------•-•----....••---.....---•-....... gesign.1 Flow.._.. °r.............................gallons per person per day. Total daily flow............................................gallons. 'Septic 'Dank——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 ( ) a _Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit`No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �rq Test Pit No. 2---____ _______minutes per inch Depth of Test Pit.................... Depth to ground water........................ .. O Description of Soil_ _____ ___________ . ___W� . ...: _. •----------•------ ----•---•------•--•- .------------- U Nature of Repairs nor Alterations Answer when applicable....__ '... ......f...__... .................................... :-------------------------•-----------.------------_______------------•-••--------------------- ------------------•-------- -------- ---•--•- -•-••-_. . `,Agreement: The undersigned agrees to install the aforedescribed ZnQidual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary —The undersigned further agrees not to place the system in operation until a Certificate of,Compliance has en i s Led by the oar f health. , Signed••• = 1 . / ._ Application Approved B ..ate y, # }" ...................•---..Date Application Disapproved ft�s the followag reasons______________________________________ ...........:....:............................•----•---•---------•--•--•---•••-••----••••••...-------•-••-. ..............................................------•--------------------- ah:;v +� Date PermitNo.......................----------------------------...... Issued........................................ Date I' a. ,<THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ' r} Trrtif iratr of Tootpliaurr ' S IS TO C T F That the Individual Sewa Disposal System constructed ( ) or Repaired ( ) b F , Instally J�` nstal 1 has been installed in accordance with'the~provisions of TITLE j of The :State Sanitary Code as described in the application for Disposal Works Const uction�;.�'ermit No.___-_-._.. ....................... dated.......................:....................... . THE 1'SSIIANCE`O_F THIS' ERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......... � '•7..................................................... Inspector..... .....::.... 'L' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH c� C ..............O F...... 3 44, .:No......._. G FEE ......... or stru tion FrrW4,Permissi 44 on is hereby granted...: ..: ..:... ._ ._ e _._ _:_._ to Const ui.( ) o R 1ep r ( an Indi Sewage ispos st at No. ' s ........ .._ .... ! . -__ _. Street -as shownt on the application for Disposal Works Construction Permit No..................... Dated...._..____._............._.............. " Board of Health DATE................... .................... :.. � -+,y, r FORM 1255 HOBBS'1& WARREN, INC., PUBLISHERS