HomeMy WebLinkAbout0076 NORTH PRECINCT ROAD - Health '7l� I�oc�, 'P-�-ec�v� (�
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THE COMMONWEALTH OF MASSACHUSETTS
��gli�� BOARD OF HEALTH
OF..........................................................................................
Appliration for Bwvasal Workri Tomilrurtion famit
Application is hereby made for a Permit to Construct (4-1-6-r Repair an"Individual Sewage Disposal
System at:
........................................ .......................
..................
cation dd or Lot No.
.... ................... .................................................................................................
00wner .. .......... Address.. .......................................................
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms ........ ---------------
---Expansion Attic Garbage Grinder
PL4 Other—Type of Building No. of persons............................ Showers Cafeteria
P4 Other fixtures -----------_----------------- ....... ..................................
< *-------*----------------*-------------------------------------------------
W Design Flow...........5�'5_ .......................gallons per person per day. Total daily flow............(3- 3.0...............gallons.
1:4 Septic Tank—Liquid*capacity_1C4:qallons Length___............. Width-_____--___-_--_ Diameter---__-__-____-__ Depth._.._...........
Disposal Trench No..................... Width.................... Total Length___................. Total leaching area....................sq. ft.
Seepage Pit No.-I-------------- Diameter,=V."::-�2..'. Depth below Total leaching areae--' .....sq. f t.
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........................
P4 ...........................................................................................................................................................
0 Description of Soil...................................................................................................................................................................i
----------------*-----------------------------------*----------------------------*------------------------------------------------------------------- ---------------------------------------
.......................... .............................................................................................................................................................................
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 TLITiZ 5 of the State Sanitary Code—,The undersign further agrees not to place the system in
N
operation until a Certificate of Compliance ha ee * u .-by the o, radf ealth...................e
Signed.. ....... ................................................ ---I.............. ...............................
Date
Application Approved By_ .e•.. ........ - ----------------_----- ....... .......
Date
Application Disapproved for the following reasons:........................................................................................
.......................
.......................................................................................................................................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
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No �. FE$:��...............
THE COMMONWEALTH OF MASSACHUSETTS
4 BOARD OF, HEALTH
..........................................OF........................----........_.........................-----........_...........__
ApotirFation for Biipnii al Works Tonotrnrtion ami#
Application is hereby mad8 for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
ttt3 �
................, orI.otNo.
f ----------------------------------Address ............
nX- � 7
Installer Address
UType of Building �• � _W..._ Size Lot___________________________S q
., Dwelling—No. of Bedrool4c—— Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of ersons____________________________ Showers — Cafeteria
Pk
YP g --------------------------- P ) ( )
Othq�ures -----------------------••------•-------•------------------------------------- � .
............................
W
Design Flow................................4t�.W.gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width.............._. Diameter---------------- Depth................
x Disposal Trench To_ ____________________ Vlf*-_ ?_.`.___._._._ Total Length..r�__�:__C�__ 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........................................
,.� 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-------_................
i
Description of Soil.....__:....................
..............
V ---•------------------------------------------------------------------------------------------------------------------ --------------•--------- . - ...------....._..-•----------
\U Nature of Repairs or Alterations—Answer when•applicable_______________________________________________________________________________________________
------•---•--------------------------------------------------------------•.
Agreement:
The undersigned agrees to install the aforedescribed Individual Se ge Disposal System in accordance with
the provisions of TIT1_2 5 of the State Sanity o he un rsign urthe grees not to place the system in
operation until a Certificate of Compliance hash eezr u
ed..-•------ -----�--e-,-�-r -----------t---•-----------------......._..-----------.. ..........................
ApplicationApproved By............................. •-----•------ -------•-----•-----•- ........................................
Date
Application Disapproved for the following reasons:................................................................................................................
-----------------------------•-------------------------------------------------------••-----...................----•---------------------------------------------- - - -----•--...__.._.
DIte
Permit, ................................. Issued.......................................................
Date
-ate
THE COMMONWEALTH OF MASSACHUSETTS
139ARD OF HEALTH
OF ................ ........................................................
t le- � �r ifirattraa�f �r gn
i rr
THIa �7a Ysir stem constructed ( ) or Repaired ( )
by :d......................................................
av
at--••---•----f----•-•--•--------•-------------------••----._._.....-•-• -•-------•-•-----••...................................-----•----•--•----..__._._...---•---•-•---•--•------------------------
has been installed in accordance with the provisions of TI '�3 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 SAT SFACTORY.
DATE................... ;> C J � ........ Inspect.'. _�/ ...................................................
!!��
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�. .....................................OF-------------------• .
....................
No.............• FEE........................
Permission is herebftranted......................._s_.._.._......_.....------- ---------------.......As..............................:.............................
to Cons V o ge Disposal System
at No
< Street
as shown on the application-for Disposal Works Constructio mit No______ _____ ______ Dated................................._........
............................................................
Board of Health
DATE-----••------------------•-•----•-------_� •� ............
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
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