HomeMy WebLinkAbout0093 FARM HILL ROAD - Health (2) 0-7 Co
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No..►. -�_.. --••-•--.........- ... ....._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF KEALTH
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� 0110 ...................I ..............--OF..........................................................................................
Allp iratiun for Diipupal Works Cnunitrur#'tun ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: Rio
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....:....... ........: .1!a.f�.r'�. � `�1 - �:.............. ------------. ..3r�c:. :��. :'..._ .....
•'//rJ�-,,��//,'/�.. Location-Address ��y/� {� or Lot No.
......-'--•-.P./�:X..._..._.G�--t.���. ..1�� .fc'Y............................. ............... 'a-"""-L:S'-""`y......................................................_.....
Owner Address
Installer Address
dType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms___......................:....................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building :........................... No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures ------••-_-•--•. -_-___-___.
w Design Flow.............. ...................gallons per person per day. Total daily flow---------:171?...__:................gallons.
W Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
Disposal ..No.......... ......... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.. '1_____________ Diameter......�.�,�....... Depth below inlet.....L(__•......... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results.- Performed. bY------••-•-•-••--•---------••-------•-----•------•---.....---•-•......--.. Date........................................
aTest Pit No. 1................riminutes 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........................
a •-•----------------•••--••----•--••-••••......--•-•--------••---....-•••••••._...'•--•-......_...----..._...__...--------•-----------------------.......---
Description of Soil --- -----
.............: --------...-•----....---------------•-••-••-._.....-•----••-
x =
y
w
U Nature of Repairs or Alterations—Answer when applicable.......�aL .Z _..___ ...... ...__S�'..L.S.._.....:5 t�-2��...._.
s- �1-,d= 4 LI . V i r. ...�.............•. ... .spit
Agreement: -
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance v tlm�
the provisions of iI'�LE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Certificate of Compliance ias-b ed by the r
Signed -- -�................ •-•1_. ...
Date
Application Approved,BY----•-----••---•.....-•-•----------------------••-•.......-••-•••-•--------•...._......---•----•- ---••--•....._....
----•--•------------Date
Application Disapproved for the following reasons:..........................................................---=t...............................................
_
-•----••--•---•--------------------------•-----•-------------------------------------------•--•----........-•---•--._._..._..----------------------------------------------------------------•--••-------
Date
��yJ(
Permit No.................::�::...- Issued--------------•----•------._........_.:.._.............
Date
No.................h... g Fss ....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................... ....................O F.........................................------.........
Appliratiun for Diupu, al Works Clunstrurtion 1rrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
....:....... Z.........:EP..9 ....9:�A ----- _DA.............. ......... Via. . t.v� .-:�. .. ...._.........-----••-•-------..........
• Location-Address or Lot No.
-•--•-•-•-••-�htlr------ .............................. . ...............45 ..Z...... ..........................................._......
Own r Address
a ._..... a •-•-- . ..........�... .... ..............................................
Installer Address
UType of Building Size Lot............................Sq. feet
�-1 Dwelling—No. of Bedrooms.............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ............... No. of ersons........_.................._ Showers
a YP g ............. P ( ) — Cafeteria ( )
d Other fixtures ....... ---•------•........................
W Design Flow..............` 7.............__..gallons per person per day. Total daily flow..........371a _...................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.......I............ Diameter....... .... Depth below inlet...... :.......... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by............................................................... Date.........................................
M Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 •-•---••...................................••---...-•••--_•__-•----•..........•-- ......._._.... ••----------
.-........
•----- ... - .._...
O Description of Soil..................••-......•-----•---.......-----•-------•--........--------•--......------------------------............--•--........•-----.......................•....
W
U Nature of Repairs or Alterations—Answer when applicable......_.hQ-�......'0.;.._......._. ._ __._... _._. ._...
... ..... ll.E�s -'�`� ... V c.vig,�t.... y •------------------------•---------------•-•-•-•......--•-
et
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T I TLE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Certificate of Compliance eex-iss by the b d
Signed--- �'
'_'""_".. I
.....------Dater•-----^-•--
Application Approved By................................................................................................. ..........
..............................
.............
Date
Application Disapproved for the following reasons:..........................................................................................................^^^
----•---------------•----•---•------------•--•-----_-------•---•--•-----------•-----•-•------...-•-•---------•--•----•-•-....----•••-•••-•--•-••...---.._...-•-•--_••-----••••--•----....•--•......_..^
Date
Permit No �-�� -_._.. Issued.........................................................
---.....-•---- ---__•.............................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........... " !' ......OF.........�,.at3'ii..✓.- .�.`...................................
(Irrtif utttr of Toutplittnrie
THIS ISC�TIF , That th In : • ual Sewage Disposal System constructed ( ) or Repaired ( )
by------------------ -------.- ... .. . ...?�. -----..........:......------•---•-....................---------...............-----.^
Insta ler
at..........................................�•-�-••--_-• c-n/_w4. = 4.�. ....
has been installed in accordance with the provisions of TITLE Lof The State Sanitary Code as described in the
F 1 d 4
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................... ..�.24 ................................. Inspector............ 1N •. ..............................
t
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/ #No`�_ :..�.'...'. > �. ......OF.......... GLI.K- � �. ............................
Fa>E.
�tu�o urku �onufrn���`rrmit
Permission is hereby granted............. ...�.,1---------.•.......�...... ................................___.
to Construct ( ) or Repair ( c.�an Individual Sea ]�a�sposal System
atNo.....................G _. ._...$kl/....... .......----------•---.....--•---...................---------------------------
.............
street
as shown on the application for Disposal Works Construction Permit
_N_o r- Dated........
........................ �- ' A -•--•-•.....-----_....:---•---_-^:a.
l2 -
-� � Board of Health
DATE...... ..........................
FORM 1255 A. M. SULKIN, INC.. BOSTON
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