Loading...
HomeMy WebLinkAbout0715 OLD STAGE ROAD - Health (2) OLd 94rlp -red . 64tj /i - /73 (14 No............ C2 Fua.. ,� -.... THE COMMONWEALTH OF MASSACHUSETTS BOARD F �EALT I---------OF............................................................... ...................... Appliratiott -for Btopiittf Works Tatudrurtiott Vrrmtit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: cation-.Address ...................... w Owern Address ,a , Z. ..................••------- . Installer Address Type of Building Size Lot... d ..Sq. 'feet V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons.----------_---------------- Showers ( ) — Cafeteria ( ) QOther fixtures -----------------------------------------------------------------_____---•-------------------•---•--------------------------------------•----__------ w Design Flow............................................gallons per person per day. Total daily flow------------------- _____.______.___... allons. WSeptic Tank—Liquid capacity._........gallons Length........... Width.....6...... 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 ( ) 0,� ��4 -`4 e�6 - a ''— 7 j— ~" Percolation Test Results Performed by__________________________________________________________________________ Date_--_•--------.-----------..---__-------. aTest Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water-.._---.-_--..--.-.-.-- f4 Test Pit No. 2................minutes per inch Depth of Test Pit--_____________-____ Depth to g ound water------------------------ P4 ............. O ..................... r R 4 --------•------------------------------------ Description of Soil------A------ -----• . ... c., ---------- --- - ., ' w U Nature of Repairs or Alterations—Answer when applicable-------------------------------------------------------------------------------.-------------- -------------------------------------------------------- :. ---- --- ------------------------------------------------------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sew " System in accordance with the provisions of Article NI of the State Sanitary Code— The undersigned ther agrees not to pla e tl system in operation until a Certificate of Compliance has been issued by the rd of alth. I D e--_ ---- -••- -- ------------------•--•-•--- _.. •----------• ---- ------ • Application Approved By--•--- ----- -- = !8r� = / Date...-•--------- Application Disapproved for the following reasons:_____________________________----------•-------•..............•-•-•-----.___.._._...-------- --------------------------------------------------------------=------------------------•-----------------•-----•------------------------------------------•------------------------.................... Date Permit No......................................................... Issued.---,1 ------ ..... Date k l --.o.-—.-.-i.--.--.-.--.-.....---------------------.__--__-__--___-_______ ________-____ --__ A No.. -•--•---• Flns.....ilr�............... THE COMMONWEALTH OF MASSACHUSETTS .. BOARD F HEALT�, ,"�,t? . ppliration -for Bttiponttl Works Tnntrnrtimn ; rrntit Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal System at: location•Address o _ > ��. Owner Address W ..................... ............. ........... ............... r..: _ .................. '� .a Installer I Address U Type of Building Size Lot.... .�..�_�?.`:'�_Sq. feet Dwelling—No. of Bedrooms--------- -'.................____._.__Expansion Attic ( ) Garbage Grinder ( ) per, Other—Type of Building -_-__--_------------------ No. of persons--------.................... Showers ( ) — Cafeteria ( ) dOther fixtures --------------------------------------------------------------------------------------- W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length-------- ------- Width------ -a.._.. Diameter_.._..�------ Deptll.__r� -_-_------ 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 ( ) O �� / o - .2 7- 7 }� aPercolation Test Results Performed by------------------------- ............................................... Date----•-----•--------------------•-------- Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water------.__.-__---____-- f14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to . ----- ---- -- - -g rnd water._.-. -----.---.___-___.. ------•----- + ..... = . a .....................•--•------' • .-- 3Description of Soil------ _------ ..---•--U x ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------- 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 Article XI of the State Sanitary Code—The undersigned further agrees not to pla th• system in operation until a Certificate of Compliance has been issued by the�ard of h41tI.I. a --- --------------- .........�--�-� Application Approved By-------- 6il. .._.. �� C.r�---- ---------- Date Application Disapproved for the following reasons------------ ---------------------------------------------------------------------------------------------------- -----.--•-•-•------------------------------------------------------•------------•-----------------------•---------------•------------------------•--------------------------------------------.--.----- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH , _ .......OF...............V-G! 'L.0 ...... .................................. (9rrtifiratr of Tontpliatta THIS S 0 _ TIF That the Individual Sewage Disposal System constructed ( �_`®rRepaired ( ) by `..... .--� ------4------- _ .................................. r lr /1an ;• -------------------- -------- has been installed in accordance with the prdvisions of Ar �lEr I of The State Sanitary Code as described in the application for Disposal Works Construction Permit No._ .__ ......... dated_._._,/-._t/_"__�7�_____________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE© AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE. / --- .. Inspector.......... --- r--- .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF EALTH 7 G ..... ........:.....'OF........ '..... --'�............................ / v No. FEE �i��n�tt� l �x �n trnrtintt �rrntit Permissi-n ' reby granted-------- r- ------ ............................................................... to Constru J or Repair ) an di 'd alal Sewag is o 1 stem -........��_._... f ,f t treet L/ as shown on the application for Disposal Works Construction it o._......._'_.__ ___,�_ll./Dpd ---...................•- Board of Health DATE FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS /OD •O d i to o � ° G 8 � �o� s FND. �gt 1 �=N 1 /00.Od ,fie,<4Sr4 ,AFD -PLO EL II- L r CC A TT I D IJ r f 4' 94 '�CALC- (I�=da Uarc 5 2I ��G d P` �V- PA6C LAB � GG�TiF� l��T TNT l=DUnJpAT/o�.1 �A XTi�iZ a N`JL- ���C., - sNnitiN NE�Eo�/ Co.cJF �S To Tfi/E QCC>!S'j'�(2L'Uj i rods e, B�92c/ST.98�E LATE -/Z//74 �ETtTIo+Jc�