HomeMy WebLinkAbout0043 TROUT BROOK ROAD - Health R'a d
LOC&.TIOP1� - SEW&C-XE PERMIT MO.
60
VILLAGE
114 -TALLER•5 U& E ADDRESS
BUILDER 5� Q &MF- ADDRESS
- �5a ��A moo— - .- - --P\4-ua --6 A- - S)ii\"LL)Lo- 6L
DATE PERNAIT ISSUED
D b.TE COMPLI &I ICE ISSUE �-76
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t- -Orao.k �O THE COMMONWEALTH OF MASSACHUSETTS
�✓ BOAR® qF HEALTH
_' .... ....--..OF.._....
GIs .. . G ..- ........................................
Alip iration -for Dia ufittl Marks Towitrurtiall Vrruift
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: L
Location-Address or Lot N
Address
a 69Y 4 ... ........................................ ••----.•-•-•--------•--------.-•---••...------------------•---------.......-•-•...--•----•----•.•.
Insta ler Address
QType of Building Size Lot----------------------------Sq. feet
U Dwelling—No. of Bedrooms------------- - ___-Expansion Attic (L Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons.--_-_--__-_-------_--___ Showers ( ) — Cafeteria ( )
P4 Other fixtures --------------- -------------
W Design Flow----------s-0........................gallons per person per day. Total daily flow------#. q----___--____...........gallons.
R; Septic TankLl!fliquid capacity/,Z�_gallons Length................ Width................ Diameter-------.-------- Depth.___--.__.-_---
WDisposal Trench—No..................... Width._.--___-___----_--_ Total Length.................... Total leaching area--------------------Sq. ft.
x
Seepage Pit No------- meter�_0QU--__- Depth below inlet.................... Total leaching area..
-------- It.
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.-----------------------
L14 Test Pit No. 2................minutes per inch Depth- est._.Pit.�_.__ ._........ Depth to ground water.....
__...____..
/�It/
O Description of Soil------ i — - ------------------------------------------------------------
U ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
W Nature of Repairs or Alterations ------------------------------------------------------------------------------.......................................................
UP" —Answer when applicable---------------------------------------------------------------------------------------------'
---------------------------------------------- ------- --------------------------------------------------------------------------------------------------------------------•-...--•----------•---•--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage-Disposal System in accordance with
the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has te issued by t � healtn
dd of health.
ne- -- ----- -•-----------•------•-------------------------- ..__ 3 ._ .
Da e
Application Approved By. ...--
Date
Application Disapproved for the following reasons----------------------------------------'------ ------------- .................................................
.........................................................................................................................................................................................................
/ f� Date
Permit No......................................................... Issued.....7-`�1- 4- ../
. .......................
Date
Y � Y
No......................... Fins.. .................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTHOF.---...AF
.
_. ea°f� ._.......................................---
Appliration -fur Ditipmal Mirks C onstriartion Prrutit-
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.................... ......................-.......................................--•----------------•--•-...I--•---
Location-Address or Lot No. {
tv
-----------------------------k- ---............ ......,................................... ---=----------------- ......................................
-•--------
Owner Address
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms---------- ____________________________Expansion Attic (I""} Garbage Grinder ( )
aOther—Type of Building --------------------------- No. of persons..-___-..---________-__-____ Showers ( .) — Cafeteria ( )
Other fixtures --------------------------------
Q ------------ ----------
DesignFlow. __.._.._• ..�........................ Mons per person per day. Total daily flow___... j. __.-_.....
W l -�. q 1 f � ;�� g -- --------- Y --------------gallons.
W
R; Septic T ankA—Li uid ca pacity��_____ llons Length Width........_-..--- Diameter__----_------.- Depth...----._......
x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No------ "________ ameter.!�0 0 0..... Depth below inlet.................... Total leaching area.----_-__..____--sq. it.
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....--_-.--_-.----.-----
�14 Test Pit No. 2_....._---------minutes per inch Depth-of-Zest Pit...... _:.......... Depth to ground water.......___--_-_----
Description of Soil_...:r:.--_-.--•-.�___�.. ...........1..�-.
U ----------------------------------•------•-------•----••----••--•--•-•---------•-•-------------•-----•--------•---•---------•••-----------•--•••-•--......----------------••-••-......-•----------•-----
W
---------------------------------------------------------------------------•-•-•------------------------------------------------------------------------------------------------------------------------
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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has,-beep issued by fthbo d of health.
S ne�l.. ` ` P ......
Date
Application Approved BY---- -- y!'" --- --- a
Date
. - ....
Application Disapproved for the following reasons_________________________________________
..................•......................... ............--
....--•-•--------------------•--•---------------------------.....---------------•-----------------•--•
Date
PermitNo.................................................."..... Issued----------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
A................OF....
e...
01.1trrtifiratr of Tom Bator
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Re aired ( )
bY ----------------------------------- --------•-.- :: ' ° x
Basta er
---
has een installed in accordance with the provisions of�Art 1, I of -he tate Sanitary Co as describe. the
application for Disposal Works Construction Permit No.--"-��-:---- dated--- ���7------------------
TNE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................. Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
G
....).X......f
BOARD F HEALTIai ,+�........ ...... .7... .. .. OF....,No. FEE
���
p O Z - -- ---- -- - -
Permission is ereby granted_"__ _ -. _
to Constr Wit/ p Re it i a Indivi ual Wage Dis allSyster�a
" - Cw.. ,rf .... .!----�`--''---
Street,
:2 ..
as shown on the application for Disposal Works Construction Pe'rryiit No-- ---- __-----
-------------------------
Boa ._. Dated_____ ________ ...........
r
w -_.,��_ ' �
fd of Health
DATE--------------------------------------------------------------------------------
S i .
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS s
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