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Home My WebLink About0101 BIRCHILL ROAD - Health �. -r I FEB...... ................ THEB®AIZ®ALT FHEALsTI-�F TS ....OF..... ............. ...... Appliration for Di-qVuiiFal Works Tomitrurtivaa ramit Application is hereby made for a Permit to Construct ( ) or Repair (Individual Sewage Disposal syst� i%�j�=�! / AA i .4-V ............ � ........ Locati dress or .. Lot No. W ow Address - �................................... � - 4 -- Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms________________________________ _Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons____________________________ Showers — Cafeteria Q' Other fixtures ------------------------------------•--••--••••--• -- 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_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................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........................ Test Pit No. 2................minutes per`inch Depth of Test Pit.................... Depth to ground water........................ Pa' - •---•----------------------............................... -------- _--------------- ------------- •----___.------__..._....------------------ Descriptionof Soil........................................................................................................................................................................ U = -----------•---••--------------•----------------------___------------------------------•-----------------------•--------------------.-----------•---••-•------------ W --------------------------------------------------------------------------•--•----------...------------------------------ ------ ---- UNature ofRepairs or Alterattiions—Answer when applicable_.....___, _P...��__---- ..__._._., _ .___- / .1 ;-/�- -�ft b 4� ..........-=i---•---------�� cr—�—?--•-- --------c --------------•--•--•----------------------•-•----•--- Agreement The undersigned agrees to install the afore scribed Individual Sewage Disposal System in accordance with the provisions of iT Li 5 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�the board of h ga lth. Signed.._... v........ ... -� ..._.._. ......... Date Application Approved BY = v/ ----------------------- ��_.. Date Application Disapproved for the following reasons----------------------------------------------------------------------------••-• --------------....--------- ...._._..:.••------------•---••-•------•------------•-------•---•---•••••-----------•----._...-••------•--------------•--•-••-----------•--••------••-----------•--------------••------•............... Date PermitNo......................................................... Issued_....................................................... Date �., THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE TH {°-001 - ....OF..... .: .................................... Appliration for Disposal Works Toustrnrtiun Prrmit Application is hereby made for a Permit to Construct ( ) or Repair (4(_ an Individual Sewage Disposal system at 4Id x ......... ; :. ... `... ._ .� ...............................:� ...:� -------------.-------------------------- . --.- fd. Locator ..... re ss or Lot No. .... �:. .... ia" ............................... ....................... ... .m .................................................... s" Owxr Y 1 r Address •... ................••.............------ ------.. - =?�`; ............... Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms................................ _Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building ............................ No. of persons................... ..... Showers — Cafeteria P4 Other fixtures ----------------------------••-- W Design Flow............................................gallons per person per day. Total daily flow.................................,..........gallons. 9 Septic Tank—Liquid capacity............gallons Length________________ Width................ Diameter................ Depth................ 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 ( ) ►-' 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.................... Depth to ground water........................ -------------------------------------------------••----.............------------------------................................................................. 0 Description of Soil..............................•-•-----•---------•-------------------------------------------------------------------•-------•----------------•---------•-•------.------ W -------------- -------------------- --•----••--------------•-•--•----------•------••-•-••-•--•• --•---------.... --------- x Nature of Re airs or Alterations—Answer when applicable - .� _______ - R -�✓ '. U PP «« >Agreement: r The undersigned agrees to install the aforetlescribed Individual Sewage Disposal System in accordance with the provisions of TTTL;; 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issuyot e board of health. y^, Signed...... - •. ---v� - :� �`..._..... 10 Date Application Approved BY........ ..!' gf Date Application Disapproved for the following reasons-----------------------------•-------•--•-------------------•---------------------------------•••-••---....------ ..................•••-•-••-•--•------••-•--•-•-•-•••-----•••••-•-•-•••-•••-••---••-•---------••-.......----•••••-•-•••••-•---•---•-•----•-•-•-----••------•••--•-••--••-•-•---------- _.....----•------- Date PermitNo.......................................................- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD PF HEALT ..........................u . ..OF..:... .: ............................... Tyrrtif iratt of TumpliFanrr THIO ,C RTIFYThat tthe Individual Sewage Disposal System constructed ( ) or Repaired by ller - s :r at........../. ..........e ........ � 11 application location for DisposalosalcVVorkseConstru Construction Permit Nol I_ ! T e State Sanitary Code as described in the provisions with the ^' - ' PPP � .............................. dated------------------------------ --• TFLE;=_ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT NE. .i';. SYSTEM WILL FUNCTION SATISFACTORY. ��y/ Inspector... DATE... . � Z� --------•-••----••... THE COMMONWEALTH OF MASSACHUSETTS u BOARD OF HE LTH �- � :.. .0.1.'............OF.. .. 0 p tt FEE. ................... No.s.. ............. Disposal k pan i>ztn rrmit Permission is hereby granted---............. =` '.. ..................................................................... to Construct ( ) or Repatr, ( a Individual ewage Dispos S tem atNo. , , a - traet ------------------•---------------------------.... as shown on the application for Disposal Works Construction Permit No.___---_- -•-----• Dated.......................................... ..................... ........ , f�Wi�,;m ---------------•--•-•---•-------.- h DATE.......................... ..................... FORM 1255 HOBBS & WARREN. INC., PUBLISHERS