HomeMy WebLinkAbout0808 OLD STAGE ROAD - Health (2) � B' 00
-711
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
................OF........... ... ......!..�a/........�J.... ....................
AVIAiratiutt -fur :43i,iVuutt1 Works Towitriartiutt Prrutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
®System at:,
........- ' l_V 9------------------------------------------ ........... � ----- ---
Location- ddress r of
Ow `Address
--- ---- -------- 'G �� -Y ............................. `��'�--�'r•--------.--------------------------•-------------------
Installer Address
UType of Building Size Lot.....ZJ_gr-_-_a._!1�...Sq. feet
Dwelling—No. of Bedrooms.............^-...........__..._.__..___.Expansion Attic Garbage Grinder (4-1P
aOther—Type of Building ---------------------------- No. of persons........... Showers ( ) — Cafeteria ( )
a' Other fixtures ------------------------------- - -
W Design Flow.................17P....................gallons per person per day. Total daily flow......._._.� ______-------------._..gallons.
WSeptic Tank—Liquid capacity,_l14_Q_gallons Length---------------- Width..-_---.--..... Diameter-_._-_-..-_--. Depth....------.--...
x
Disposal Trench—No..................... Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft.
Seepage Pit No-------Z--------- Diameter.....i9k.9.... Depth below inlet.................... Total leaching area------------------sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) _ 6 -/z- 7Ci
a Percolation Test Results Performed by----••-------------•-----•------------•-----------------................ Date........................................
,a Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water-_..___.__---._-.------ '
rXq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_-.-___.---.__.------.
G •-----------------i�--- -. i� ;---- - ------------
Description of Soil------ 0 �E' ---.` 1 Z. . V f �1
w
VNature of Repairs or Alterations—Answer when applicable..---------------------------------------------------------------------------_------------
----------------------------- ..-.
l
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 ees not to place the system in
operation until a Certificate of Compliance has been is the boar health.
igne _-�'•--_'�' ---- .....- '' -•----------•------.
Date
Application Approved By. - .... ----- -•....% { �_
---------------
Date
Application Disapproved for the following reasons:-----"---------------•-•-------Z
-"-------•-----.......----•-•-----------........._._.....--------------•--
................"-•---------... ........ ---------------------...........................................................................-----•----------------------•-----------------.-•--------------
Date
PermitNo........................................................ Issued........................................................
Date
614-3
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
'.� ";ice.. ,_. .,•� ... /�...............O F...............
Applirtttion -for '%ipoiitt1 Works Tomitrurtion Prrui t
Application is hereby made for a Permit to Construct ( ,r.-)or Repair ( ) an Individual Sewage Disposal
System at
..
Location�ddress ,�-7 or Lot Nd.
.......................... .......................... -----..----- -•---------------------...
Ownc�- Address
.......................................•----------------• ------------------••--•--•--• ------------...------------•----------.....___--------- ----
Installer Address
Type of Building Size Lot_..__. % ___5 q. feet
U Dwelling—No. of Bedrooms............... Expansion Attic (,IA) Garbage Grinder
p, Other—Type of Building ---------------------------- No. of persons----------- Showers ( ) — Cafeteria ( )
a' Other fixtures ---------------------------------
W Design Flow.................. .___.____.___._..__-gallons per person per day. Total daily flow....._...... a_�'..._._._..-._..gallons.
WSeptic Tunk—Liquid capacitv,�!�G_gallons Length________________ Width................ Diameter---------------- Depth_....___.._....
x Disposal Trench—No----------------------- Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft.
..... Diameter.....GS'___. Depth below inlet.................... Total leaching area--------- ft.
Seepage Pit No______________ P L, g t 1•
Z Other Distribution box ( ) Dosing tank ( ) 64, /-2C/%17 - 5-' / 7` 7G,
aPercolation Test Results Performed by................ --------------------------------------------- ------ Date---------------------------------------
Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water.-..----.------------.-.
(� Test Pit No. 2________________minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------
Lei ---•------•----•- ------.. ! =
6
O Description of Soil..... ' -------------------------
UNature 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 has been issuedbythe board of'health.
';Signed/'. ~ .,,-✓ - FD
/�
APPlication Approved By._------ -- - G I.....C_:_.___� �/!.✓1 1 /_- G--l>3'.' r G-
Date
Application Disapproved for the following reasons:-------------------------------------------------------•-----------------_-..--••-•-------•---•------------•----
--........--••---------------••--•-•---•--•--•---.._..----•-----------_..---•--------•--------------•----•-----------------•---------------------------------------------.---.----------•---------------
Date
PermitNo----.................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.'� ..............0 F..........`' :..., ..........................................................' .
w.prtif irttte of fillImphatta
THIS IS TO CERTIFY, That the Individual,Sewage Disposal System constructed r`Repaired ( )
b � —="--------------- J-l�. t r- .x.-y - ------------------•--•------•-----------------------------------------•-•-----•---.•-----
,�! Installer�/
at-- .. '---'�--------------------------------------�/��/ / /f.-7_ "`K'-tom =
has been installed in accordance with the provisions of Ar ' l XI of The State Sanitary de as described in the
application for Disposal Works Construction Permit No.-_C-AV-----6;_Q.3----------- dated.- ._- I.. 'f :._._..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
f r
4
DATE--- �"'` , .� ._._ _ / r` Ins ector
. f
THE COMMONWEALTH OF MASSACHUSETTS
�� -- BOARD OF HEALTH
? ...:�... ..G-...�.............
.OF..................',.........-*......::..!.................:..... .... /�
No.. ............... FEE...2-----.............
�i��tt,�tt� ttrk,� C�>att�tr�trti�a$t rrutit
Permission is hereby granted-------------'fe_ i :__________ 1�rt _...___._.....- ... .... ..............................................
-------------------------••••---••......--•-
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
- -
Street
as shown on the application for Disposal Works Construction P it Dated_. 7C
Board of
DATE...................................•------.._.---------------------------------
x tl,
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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