HomeMy WebLinkAbout0117 ROLLING HITCH ROAD - Health (2) 4erv� (e, , ✓r� a 3 -
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.. No..... .../ Fug.........Zisposal
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THE COMMONWEALTH OF MASSACHUSETTS
��- BOARD OF HEALTH
�� �� _..,....... ... .... ......OF.................................................... .................................
Appliration -for Biiipviitt1 arkii Tutuitrurtion Pum' d
Application is hereby'made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage
System
------------ --------- ---- -e ------ ..--�� i--------- ../4
c ion Address or Lot No.
Owner Address
-- y ...
/ Installer Address
d Type of Building Size Lot.�s��,. ��. _Sq. feet
U Dwelling—No. of Bedrooms.._____ . --__.Expansion Attic ( ) Garbage Grinder (__._
Other—Type of Building Gl/ / , To. of persoiis.._____ .............. Showers Cafeteria ( )
Q' Other fixtt �/
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. .................... Widt ---- -------------- Total Length-................... Total leaching area--------------------sq. ft.
Seepage Pit-No...._---�-------- Diameter_ A.e_ Depth below inlet.................... Total leaching area_�'J. e-4? sq. ft.
z, Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-------------------------------------------------------------------------- Date----------------------------------
aTest Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water---------.---.----..----
G14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------
P4 --------------------------------------------•------------------------------------------------------•--•---•--------------------------------------•------- -
0 Description of Soil........................................ ...............
---------------- --------------------------------------------------------------------------------------------------•--------------------------------------------------------- ----------------------- ..
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 NI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued byt&eoard of he lth
Signed 1/SO
/C Date
ApplicationApproved By-------------- ---- -----------------------------------------------------------------------
Date
Application Disapproved for the ollowing reasons-----------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------•---•-----------•-----------------------------------------------------------------------------------------------
7
Date
`j '-1-7 7 / .
Permit No. = Issued --------------------------------------------••••-
Date
f
1, '•
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
• ................... . . . __............OF..................................... ............;........... ......................
Appliratinn -for R-4pagal Works Tomitrurtion Vamit
' Appl`ication is hereby made for a Permit to;Construct O or Repair ( ) an Individual Sewage Disposal
System
Jr�7c hon•Address for LN 0
....4-1..../.-_"� .-----4-7.................... ..
Owner Address
- ------------------------•............ ..--------------------.._.............................
Installer 'Address
U Type of Building Size Lot,�,,,t.7___9_?..Sq. feet
Dwelling—No. of Bedrooms-----------
-••---••-___-----___---.Expansion Attic ( ). Garbage Grinder
aOther—Type of Building! ' : .�rz o: of persons...--- ______________ Showers ( L) — Cafeteria ( )
Other fiXtLIECS
G "a
-------------------------------------------------------- ..................... -------•---.........._.._.... A ..._--.--•------------•--------
w Design Flow__________________ ___4*_...._I�Ogallons per person per day. Total daily flow......_ r, .-_---____.-.-----..gallons.
WSeptic Tank—Liquid capacitw4gehrgallons, , Length---------------- Width.--__-.----_--- Diameter---------------- Depth....._.--._.._>
x Disposal Trench—No- ______________ �1fidt _-. __-----__-- Total Length----____. --___--. Total leaching .......sq. ft.
� Seepage Pit No.........�....___ Diameter._ .:_ _ .�_ Depth below inlet____________________ Total leaching Yireaj'OVd__..---sq. it.
Z Other.Distribution box ( ) Dosing tank,( )
Percolation Test Results Performed by:------ --- ---------------------------------••-••--•••--•-------------_. Date............... --------------------
a
Test Pit.No: .1.........:......minutes per inch Depth- of Test Pit.................... Depth to ground 'water--------_------------
.
(s., Test Pit No. 2________________minute�,per-inch Depth of Test Pit .._.........__. Depth to groundwater__:.-.-_____---. --. .
a >x .-. ------------...................................................
O Description of Soil----- •----•-------..'` ' ---------------------- • ---------- ----- -- ----
x ------- > ,r`�,`'--------------- ----------- -----
c,
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 has been issued by t e oard of he Ith
Signed.........k'!.. ... .......... _----------------..................... `-.
1C-"--` Date
Application Approved By-------------- _
•------•---•--------•----•---------•--------•---------------------- ........... --------------
Date
APPlication>Disapproved for the oflowing:reasons-------..............................................................................................................
—/-7 Date
PermitNo..------. - =-----------------•-••••-......... Issued.--••--. --•-------------------....................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD - OF HEALTH
/........ ............OF.............:e.!f�fkJ1 �G.......
Trrtif irate of T. Mplian i
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( 7() or Repaired ( )
by........- .4.A1.........t �! /, ..................................................................................................... ....................................
Installer
S , of7'......................... ,
has been installed in accordance with the provisions of article XI pf The State Sanitary Code as described in the
application for. Disposal Works Construction Permit No:'_ ----- --------------- dated------------- '_/7... 7.............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM MILL FUNCTION SATISFACTORY. :
.PATE--.......
--- :: �_._.. r Inspector• , •-•--
THE COMMONWE -L-•T;H,, E MASSACH TTS
y,;y� Iydl�
Y
BOARD Ole HEALTH" '
Al
.:... ?' ..`�-..OF............. .!!.''r<!
J T„�
No..... .. - ', �Ji FEE
;
Permission is hereby granted +1 ........... -------------
to Construct ('X) or Repair: ( n Individual Sewage Disposal System
at No.
_< < �Q / ✓ J�"G ------------ --------
_ f
9z Street s°
ass own on the application for�Dis sal Works Construo- m er itNo.._-___ ____7 Dated--_- --fir` '' "°'
................. ...........
-- _-_-__
c and of•Health
DATE....................................................
t; ur
FORM 1255 HOBBS & WARREN. INC PUBLISHERS
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