HomeMy WebLinkAbout0099 OLD POST ROAD (CENT.) - Health (2) 9� Old hs�- 0. ) (In�l
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No.--_... _ ..:5.....-- / Fu$...l'It................
THE COMMONWEALTH OF MASSACHIbSETTS
BOARD OF HEALTH
i `J.
/ 1 ®� •..................•........_..----•-
Appliration for Disposal
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: p�
.... l oc �
rLocation-Address t o.n
Owner Address
} ......................-------------------------------------
a I
Installer Address //��
Type of Building Size Lot.,l. ......Sq. feet
Dwelling—No. of Bedrooms:.... ......................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ________-I.................. No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ............... -------•-----------•-•---•-•-•---•--•-•--.......•-------••-------••-----•-••--......--
W Design Flow.......ll ........................Lgallons 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.
Seepage Pit No-----------------_-- Diameter.................... Depth below inlet.......:............ Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) mm_ �yG`%&.-L -7-/ -- /'~ Percolation Test Results Performed by-------------e. ...._... :!�....-...•.._.._.............. Date_2..-.rC, t_�'.../..•.........
a
Test Pit No. 1..:�)A-..._._m nuts per inch Depth of`Test Pit.................... Depth to ground water........................
(Z4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Description of Soil-----------4- ..... a !c 4(. �•�r , �` ..
V -----------------------` �..
---••----•----••-------•----------•----•------•••...................••-••----•--....
---------------------------------------------------------------------------------------------------•-------------------------------- ---------------------------------------------------------------•--.
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 TITL% 5 of the State Sanitary Code— The undersigned further agrees not to lace the system in
operation until a Certificate of Compliance has been iss by the srd of health. ��pp
Signed-^---•-•_-•-'•-••-• ....................•---•• --•------•-------• " = �•.r7 .----
Date
Application Approved By....... ..,���.... /,eel l••c i ( _- ---- --.�/_.---------�-
-•;�•----•------•-- / Date
Application Disapproved for the following reasons---------------------------------------------------------------------------------------------------••----•-•---•-
--....•....-•-•-------------------•------------......--------...-•-------...-----•----••---•---------------..........---•-•--•---••-•-•••--............................................................
•--_..... Issued.. '.C .'
-----------------�•----a�
Permit No --•---
Date
077�j
Ir
No.........7..._._....... Fss..........................._
y, THE COMMONWEALTH OF MASSACHUSETTS
M , =BOARD QF HEALTH
4 . ....0 F.................. '..................................................._.._
Appliratiun fur Disposal Works Tumuurtiun Vrrmit
' . Apphcatioii is hereby made f or_Z Permit to Construct,,( ) or Repair ( ) an Individual Sewage Disposal
Syst at:
`/ ocahon Address r t
el
Owner Address
W __
------------------
Installer Address
Type of Building Size Lot.A "-'a 0.......Sq. feet
U Dwelling—No. of Bedrooms_....::.:...................... .....Expansion Attic ( ) Garbage Grinder ( )
............................ No. of ersons_._.____._________.____._.._ Showers — Cafeteria a Other—Type of Building p ( ) ( )
QI Othe fi tures -•-•--•--•---•---------••.......- .
W Design Flow.......
:__ ___________________ _________gallons per person per day. Total daily flow..................... ....................gallons.
R' 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 belovyfinlgpe .__,wTo l hirtg idea..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) !'v� '��''
'~ Percolation Test Result�� erformed by...................................................... �^�� ?
JJ ._ _.. --------------- Date------------------•-----------.._...---
a1 Test Pit No. j'_______________14RMMs`per inch Depth of Test Pit.................... Depth to ground water_____________._____.._-.
�14 Test Pit No. 2......:.........minutes per inch Depth of Test Pit.................... Depth to grounsl water............ .........
it
R+' t rl
0 Description of Soil.. + "..` --_...-- ----•-•--•--•-- •--• - ---
+J ---------------
•-----------------------
••-•-s,-•- •-•----------•--••---•-.---- " ------•••---------------•--------•-•-----•--•••-------••---------------- --------------
W
------------------------------------------------------------------ --------------- ---------------------------------------------
U Nature of Repairs or Alterations.—Answer when applicable..........................:::___._..._.....__.:_-.__.._____.___............._,.._..._...._.._..
-•--------•----• ................ .--••- ..: ---•-•. ......................
4.
Agreement:
d r x
The undersigned agrees wo,install the aforedescribed Individual Sewage.Disposal,System in accordance with
the provisions of TIT1Li 5 of the Statee"Sanitary Code The undersigned further agrees not to lace.Ihb system in
operation until a Certificate of Compliance hasp been iss by th1 �f"health a Q•, u
C
Signed_
t
got
.___.. R. ....... . ...... ......Application Approved By.......
`
I Date
1' .
Application Disapproved for the f ollowmg reasons:-------•--.............................................. -
............................................ .............................. ..........................................................
u---------- --- �` Date +
Permit No...........................:.......•--...--••----------• Issued_......
,
Date
THE COMMONWEALTH OF MASSACHUSETTS
1/
BOARD O HEALTH
(9rdifiratr of Tuntplianrr
THIS IS TOP`CERTIFY, That the Individual Sewage Disposal System constructed ( or. epaired ( )
In
.At ,. " . � �� -•--- ---------- -- -----
has been installed in accordance with-the provisions T he to Sa.nitar C e described in the
P /� Y
application for:Disposal Works Construction Permit No......................................... dated___`- : ... ....2�''7'�.:.....
THE`'MSUANCE OF.THIS CERTIFICATE SHALL NOT BE CONSTkOE® AS A AR NTEE THAT THE
SYSTEId WILL FUNCTION SATISFACTORY.
DATE......... -% 1 .�-,/ ............ Inspector ..........----- -............ ..................
'-THE COMMONWEALTH OF MASSACHUSETTS
„ Y rBARD O HEALTH.F
..............I ! ".. '
f.A
...
No..:........ FEE r� s .
` Disposal, arks Tunotr Wu vrfmit
1
Permission is Hereby grant d....... .......
--- --- .......................
...............................
to Construe r Rep �? �Ind ivld S Is siS' t r'
at No.. -- .
- ,
Sfr+e `77 ., ,.
..,.-as"shown on th application for Disposal Works Construction Per" a d... ............. �
M1 .............. ..........'-.. .........W .
......
oard of Health
DATE----.-- w 77............................
)"%FORM 1255 HOBBS & WARREN, INC., PUBLISHERS V -'.
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