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HomeMy WebLinkAbout0697 OLD STAGE ROAD - Health (2) 69'1 M( 3-6�z W I _ - 0611 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . .... ._.OF....... � _` - - - - W . Apphration -for M_gpofitt1 Worko C owitrurtion Urrmil Application is hereby, made for a Permit to Construct (K or Repair ( ) an Individual Sewage Disposal System at .......�1 ---------- . ------ _` � ----------------- ----------- - Location Address �•-�, or Lot No. ------------------I ©' ----_------------------ C� tr�..l -Q---------------------...-------- c� /� Addre Installer Address Type of Buildin Size Lot_..{....._�.-(/ __Sq. feet U Dwellin -No. of Bedrooms------3................................Expansion Attic NO- Garbage Grinder ( ) p-, Other—Type of Building ---------------------------- No. of persons-.-------------------------- Showers (-p ) — Cafeteria ( ) Q' ALiqruid fixtures -----------------------•------ •--------------•------- W Design Flow-- ..._.._ Mons per person per day. Total dai w_-__-___G�1 �.... g ---------�-`-�----------- g� P P P Y• -- ----- -- --------------gallons. 04 Septic Tan capacit� ._--gallons Length----C-------- Width-.-_--.-Diameter_-----_-..._-__ Depth.__.---_------- W Disposal Trench—No. .................... Width-__----_.___..---_-_ Total Lengt .................... Total leaching area--------------.-----Sq. ft. x Seepage Pit No--------------------- Diameter.................... Depth below i et___ ___ ___._. .. le hiug area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 411�11 . Percolation Test Results Performed by...... ------------------------------------------------------------------- Date---------------------------------------- ,al Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water...---_ _-.--__--.--- (_, Test Pit No. 2......_---------minutes per inch Depth of Test Pit :._.._.....__..._. D pth to ground water------------------------ O ----- �- ----------------- Descriptionof Soil----------- ---------------•---•-------------------------------q� ----- -- .. ...---- ............----- i , �� P__--___ __ ____________________ ----------- ---- --L_, ----- -- - --- ------ ----- �^p Y - -�� ---- x •-------------------_---------------- .-.------------------------------- ---- ----------------------------------•------------------------------------------------,--------------`------ V 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 Article \I 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 [� > Signe .... .. .. ^:......��......•. -•---------------•-•----•-- �j� D9te Application Approved B �" ........ / �/ � _ �/ T( ---.. PP PP y---•- 1 Date Application Disapproved for the following reasons:................................. ------------------------------.--------................................ -••.-•-••--•--•-------------•---•-----.............-••---.---------------.•-----•---•-..----------•-----------•--.-----•-------•------.--••--------.----------------------------------...---•-----.----- Date Permit No......................................................... Issued....... .........gig d...�.'� Date —_-_ -_ ------------------- _-- `--- - -------- No..- --------- THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH 1 ............OF.......41F . I Appliratinn -for Ii,4puiial Works C owitrurtion 1hrntit Application is hereby made-for.a,Permit to Construct 05 or Repair ( ) an Individual Sewage Disposal System at J//' )�y`� L�ocathio`n-Address * t //'^' C7 i orQLot ;o. /I n ----+"}--1------------n------'*-"..... '=------...... ---n------B--Y---------------------------- ---------------------- --R---------'1.1�...--[/---....------------------...---.....---- W -----�,—--�-'[•--- ......-•---OV G y� Addre� /� ' Installer Address Type of Buildings Size Lot_._r.___..r-�! __Sq. feet '-, Dwelling/—"No. of Bedrooms------3................................Expansion Attic 0,/0 Garbage Grinder ( ) a4 Other—Type of Building ____________________________ No. of persons---------------------------- Showers Cafeteria ( ) Q' Otl r fixtures d W Design Flow________ ____ __ ....._.gallons per person per day. Total dai w.....___ _U'a____ g �-------- g� P P P Y• ---- --------------gallons. P4 Septic Tan —Liquid capacitly ___gallons Length_______..._. Width..____..Diameter___._...._.._.. Depth._.._____...-.. xDisposal Trench—No_____________________ Width-------------------- Total Length-------------------- Total leaching area..........._........sq. ft. Seepage Pit No--------------------- Diameter----_--------------- Depth below;('let__. _________ _.. to} leaching area-------.----------sq. ft. z Other Distribution box ( ) Dosing tank ( ) � � Percolation Test Results Performed bY.......................................................................... Date----•-------------------------------.-.. Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water..-.-_----_-.-_.-------- (� Test Pit No. 2________________minutes per inch Depth of Test Pit-------------------- D pth to ground water-..._._--__-___.-___-... t� - - - c, -.7..-•--•--""......---•-••-----••----------------•------- D �_.. Descriptionof Soil----------- --------------------------------------------------- a/_ -� -... -------------------------- .........------------ ------ x �-------- ------------- -- W VNature 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 ha een issued by the board of health. -------- -------------------------•----- A Application Approved B ` ate PPPP Y------ - .......... ..... Date Application Disapproved for the following reasons__________________________________ ________________________________________________________________________•---- .......................................................................••--------.......•---------------------------------------------------.........--•--------------.-•--------------••--------••-•- Date PermitNo......................................................... Issued...................... ................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF7 HEALTH .':... ..... ..............OF............... ........................................... rrtifiratr of Tilutplianrr THI• I TO CERTIFY, t the Individual Sewage Disposal System constructed ( ) or Repaired ( ) -------------------------------------------------- Ira e at- ` � r G t9--- ----------- -tea-{' has been installed in accordance with the provisions oi I XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit N �___- _ S''_--__- dated._?_.--_ -_---'.�_:1 ...... THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH �2.�. C'' � 7/y ......OF.......... - � c ,�t,.%J / No.--------�..... FEE/Z ._............. 'irivrrti � urk,i � strurtiun rrrutit Permission is ereby granted_..._� �^-�J.._.... . to Con ( ) or Repair Y'arl/In ivyual Sew D po&�� at No.7t f '' S.../iVc?CC- %..f?.... 1 -- - -- - - - - -- - -- --- ----------- -- Street 7 7 as shown on the application for Disposal Works Construction Petit ;______ ___ _____ Dated__7!_.___ ._..___._C_✓_____.... ------ - -- 1 �� ��� � oard o Health i DATE...............-••-•-------•-••------........................................... FORM 1255 1iOBBS & WARREN. INC.. PUBLISHERS •t �..... _ - _ ,. "ice ",a`-� F r+ IR- q� '=e ; .- ,.� - - - - .. __. �. - _ � ^•dam - IQ .yam -A - _. - _• - - - - - Q J - � t _ M :It T - L d'T G �► f - 0 1oj 0 Al . ' C TTFl- E. D ( PL' OT - PLAN - Cz—iCL 7-E-,e t` t3EaFtoN F E R_E N C.'E= �ic/cf' L aT :/E' .9.5, ti'ow.�i y � T C ll9N IT D A T E.:.- Az' OS /iE/ PGRit/ B'00� 2'Ci Pi9rj E - 1 KE.REBY _. CE. RTIF .Y THAT: .THE .8u, ILO.IN:G RE-G L ;A D SU-RVE:YOR: . 5t{OWN_ ON' TH`t-S: P' L,AN 1S -LOCATED O-N TEE. G:ROU._ND AS .SHOWN HEREON; Ashtp Ttt / .T (. T CONf0RM To :-THE ��HOr s ►- txrvrN: G QY - LAWS ot= _T ++ E TOww QF �� Sr t j .r13r�BG WHEN CONS;T R Vzit T E- D g �fORGE JQ� B / RNSTA.BI. Y CCN � ILTANt' tNC � { -, WE`ST �4Rl0UYH� MA