HomeMy WebLinkAbout0185 ROLLING HITCH ROAD - Health (2) f� = /per-iao __
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA TH
.. . ...........O `•!.`S.j.,zfd'^.'.'V..r.- � -----------------------------••--•-•
Appli.rntion for 19in.Vooai Works Tonitrnstion rumit
Application is hereby made for a Permit to Construct (.4 or Repair ( ) an Individual Sewage Disposal
r'System at h
•-T�' . _ ' ""yt --�--'- -----------•--•_• •�--.. .-'`� . ...........................................
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lb /f oration ddess or Lot No.
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.. a....__! _•___ ....�. �•"''�+- S S, ................................
_...____•......................... .t` s_f�ts.1. --..........--.........__............................_..---
r a Owner Address
q:
Installer Address
Q Type of Build Size Lot__. .'�.+%"'. ._.'S feet
Dwelling No. of Bedrooms._-____:� ----------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures M-------.-••------------------
---•----•--•----------------------•-----•------------------
W Design Flow......................... .......gallons per person per day. Total daily flow........ .._ ...•._----__-_gallons.
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WSeptic Tank-V Liquid capacity 1:,{;----__gallons Length................ Width....._._...----- Diameter---------------- Depth__.-_--_---._...
x Disposal Trench—No. .................... Width.. _..*.. Total Length____---_-____ ___._ Total leaching area----- ..........sq. ft.
Seepage Pit No...:...../.......... Diameter,-.,Y _'bepth below inlet---------:t...... Total leaching area_. f'A-sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date----•-----------------------------------
,� Test Pit No. 1................minutes per inch Depth of Test Pit_-______-_-__-__-- Depth to ground water.-.-_-----.--_--_----___
P;q Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground
a
water__--.---_---_-_-----___
x O Description of Soil---------------- - r E --- ?
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x
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W
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 furthgrees not to place the system in
operation until a Certificate of Compliance has beep
pi by the boar
S1gne�Y` f
......................
Date
Application Approved By---- '" . ,--•-- t- 14
---- •-• -
•r - ✓" ate
Application Disapproved for the following -reasons:----------- ......... ............................................ ....................................
----------------------------------------------------------------•------------------------•-••---•---------------•---------•------......•-----•-•----- -------------------------------- -----------_---
Date
PermitNo........................................................ Issued........................................................
E Date
tffia.
s THE COMMONWEALTH OF MASSACHUSETTS
BOARD , OF HEALTH
...... .........OF....... .........................
fe
urtif iratr of ToinViionrr
THJS ISjO CE .TTI Y, Thit the Individual Sewage Disposal System constructed ( or Repaired ( )
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b .� -go- «� :: p`j
� �+ �� 4 Instiller ` .a tip
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has been installed in accordance lhelprovisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ...._ ______________ dated. .. _. .. `___..__.__.
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,F HEALT
> OF..........
r .t ...............................................
No. ff ........ -•----- .
B ork =34—rat ioi r ntit
Permission is hereby*granted.. �. �, { '--- -_. .. °
to Constrict � ) or Repair ( �`) n Individual Sewage Disposal ystem 7' '
at No. rye f - • �t '
- -
6 Street
as shown on the application for Disposal r orks Construction Per iiit N �._ Dated__ , �'. --------
"' / >;
ti
Board of Health
DATE . ----
...............................
• ,,� . ' ..
FORM 1255 OBBS & WARREN. INC., -PUBLISHERS -