HomeMy WebLinkAbout0083 EDGEHILL ROAD - Health S`3 Eda�e FI�II e/•, {k�nu
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L O CAT ION SEWAGE PERMIT N0.
VI LLLAAGE
/,OR
I N S T A LLER'S NAME i ADDRESS
e U I L 0 E R OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED lo _ v2q _ 79
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THE COMMONWEALTH OF MASSACHUSETTS _f
}x. • _ BOAR® OF HEALTH
,
....... OF...............::�....�'...... -----
..............
App iration for 1iopos al Workii Tonitrnr#ion ramit
Application is hereby made for a Permit to Construct ( ) or Repair (y(-) an Individual Sewage Disposal
Systp
- _... ----------•
j Location Qddre or Lot No.
ja
4' � ._......... lT4v'J= ......................
...................................................ar..............................................
a ..........Vti..¢.�lin. 4...... / .............................. .............. •�
Installer Address
UType of Building ,!� Size Lot.................:..........Sq. feet
Dwelling—No. of Bedrooms...............--..___-----___--__--Expansion Attic ( ) Garbage Grinder
aA4 Other—T e of. Building __-_. No. f erso s....._..._
YP g ----=------------------ P -------------- Showers ( ) — Cafeteria
d
Other fixtures ..................... ._....._ --
WDesign 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.
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. I................minutes per inch Depth of Test Pit.................... Depth to ground water-.___---_____-__-_. -.
Lz, ?Test 'Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Q+' -------- ............................
O Description of Soil................. ^-r ____ `'-
x
W -------••------------------------------------------------------------------------------•--•------------------- . ................................................-
U Nature of epairs or Alte ations Answer when ap icable.___________________ _44______________zF�..'....... __._......
....
.......... �•------------------------------------------------------------------ ---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 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 health.
Sig A. 7.
---••-•------------------ --•---------•--.- -- --------
pp,� / ate
Application Approved By.......- ---- ---- _-- - --- �................ —.CS_.._.�.1 .-_. :
Date Application Disapproved for the following reasons:.......................................................................................... -•_____
................•----------------...-----•------------------......---•--....-----........--••-----------------•----------•--•--•----------•-----•---------------------------------------•-----•---------
PermitNo......................................................... Issued_. ..... .........................................
Date
01q
No.. FEB 11...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH .,
2.
A^ 141�
14 ......... I.... ....... ........ .................-----.............._OF................. .....
Appliration for Dispos a* t Works Towitrurtion famit
Application.is hereby made for a Permit to Construct or Repair A) an Individual Sewage Disposal
Sys
----------------X..3------------------
Locatio �res ' or Lot No.
. ......................
............ ................................................................................................
dr SS4
%A ............. ............... ..............I - --------------------------------------
Installer Address
Type of Building Size Lot............................Sq. feet
aU .... ......................Expansion �dtic ( )
Dwelling—No. of Bedrooms.......... Garbage Grinder ( )
Other—Type of Building ..................... ..... No—of persqn�,---- -- ----------- Showers Cafeteria ( )
.... I .. .................................................................................Other fixtures .....................
Design Flow.............I...............................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. f t.
Seepage Pit No..................... Diameter.........__..___..__ Depth below inlet.._......_...._.__.. Total leaching area..................sq. f t.
Z Other Distribution box Dosing tank,(
�4 Percolation Test Results Performed by.-----------------....................................................... Date....:.._.........._..._..._.. ..............
Test Pit No. I................minutes per inch Depth of,..Test Pit..............7.�... Depth to ground water_.___-____-_ _.t,—..__.
Test Pit No. 2................minutes per inch Depth of TeA.Pit..............._:... Depth to ground water------------------------
P4 ....................... ... .......................... ...............................................................................................7,
401 0 Description of Soil.................�pp W........... .......... ...........................................................................................
US
.......................... ....... .... .. ...............................................................
------------------------------------------------------------------------.......... ------- ---------------------------------- .........
. .............................................................. .... ...
Nature ofPepairs or atons An
swer w en ap livable
U"
. ---------- ;.... ..............
-01
............ ..................................................... ......................... .................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 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 health.
,S' -------------
9 ----------------------------------------------------- ----------------
j ate
Ap K,70
plication Approved By.....
Date
Application Disapproved for the following reasons:-,,..................................................................................................................
.............................................................................................I I...................................... .............................................................
Date
Permit No.. Issued. ...........................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH,
'a OF..... . ....4.................
ptiatta Tntifirair of Tom
T .0 CERT That the Individual Sewage Disposal System constructed or Repaired
b . ..... ...4e... ............................................
-- - - -----?------------------------ --------
I js
----
- - ---------
has been installed in accordance with the provisions of e State Sanitary Code as de5cribrd in the
application for Disposal Works ConstructionPermit N042A ................. dated_.. ..............
THE ISSUANCE OF THIS CERTIFII&ATE SHALL NOT BE CONSTRUED AS At GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......... ...................................... Inspector---. ..... ............................... �.;,.....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
A
1'7� .. . .......... . ...........7 . ...... ... .......OF.............. FEE.
I.............. .................
Permissionis hereby gr t . .. .. ...........................................................................
to Con I Re air. an IndivjdiLal Swa Ins s
ol;
a t N o.. .. ....... ..
j
...Ira... . . ... .....
S et
as shown on the application for Disposal Works,Construction Pe
rmi o...... ......... ed..pP__t. .. ........7.9i...
N(9
........... ....... .......
Boar of ealth' �aE
DATE.. ......... .....................
.........................
FORM 1255 H68BS & WARREN, INC.. PUBLISHERS
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