HomeMy WebLinkAbout0033 EDGEWOOD ROAD - HealthI�33 Cdy(didd Pl., "s
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
..................0 F.. ����.. 1��...... ...
Applira#ion for Disposal lVoris Tonstrur#iun Prrutit
y Application is hereby made for a Per rut )�epair ( ) an Individual Sewage Disposal
3 S�� t ------------------------------ - .-.------• ---•--------------------- -
Locati '-Address
� � - r Lot No.
�w Owner 7Address
W 'Z�
If -------------------- ---------------------- .............................................- ...............................................
In aller Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.............p. ..._.........•..___-__--Expansion Attic ( ) Garbage Grinder
Other—a Type of Building .... No of persons............................•-------_.....
YP g ..................:..... � P Showers--(----)--- Cafeteria.(... )
Other fixtures --------------•-•--•------- ti -- ------•----•-----•------•......._ m.
W Design 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 ( )
aPercolation Test Results Performed by--......................................................-................. Date........................................
,.� Test Pit No. 1................minutes per inch Depth-of Test Pit.................... Depth to ground water.....................
__.
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
R+ - ----------•---•--------
ODescription of Soil = ' j ?-' --...............................................................s ---------..•..---•--••----------•--••-•-•---•---••-----•-••-•---•-••-•---
W •----•----------- -------------------------•-----------•-•----------------..................................................------••-------�-----/
U Nature of Repairs or Alterations—Answer when applicable.____ d�j____-- :: ....................... .........................
....------•--------------------•--•--••-•--••--------------....-•-•
Agreement:
The undersigned agrees to install the aforedescribed Individuals Sewage Disposal System in accordance with
the provisions of iIT E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b n issued y the board of health.
Signe �
`------•---...--•----..�...... .......................•-- ---•-- ..__Date.....`..._
ApplicationApproved By--•---•----•--•---•-----------•-•-----..::...•-••-•••-•••........................•-•---.........
Date
Application Disapproved for the following reasons---------------••-----------------------•--------------------•--------------•--•-------.........-----.....•--...
--------------------------------------------------------------------------••---------------•----.....-----•--•-•-•------••---•---•------•-•---•---••--•--•-----•---....................................
Permit No._--�:-�4 - Issued_....�----�_7
Date
Date
T• .. � 7 dc`
'.""........... � `h
• THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HE
ALTH
ALTH
�
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O F
Aplilirtttion for 14spmttl Worko Tonstrurtiutt ramit
Application is hereby made for a Permit%o s ru t ( )�` »epair`,( ) an Individual Sewage ;Disposal
Sy at: "'t '
t-�V4"7" s ." --------------------- .......... ....--•--..... .----•---•-----------•---•-- •--......_
Locatt Address 1 or Lot No.
.. ..1..... -- -•---------•.............. c ..-
.: Owner .....
Address
•---------•................................•-•--•••••..._-••••_-•-- ....__.a.................:..... ller _
Address
d Type of Building Size Lot___.........................' Sq. feet
U Dwelling No. of Bedrooms......................::..... .-Expansion Attic Garbage Grinder e:
r
p1
Other—Type g _________ ____ No. of persons__.________. ._._•_ Showers ( ) — Cafeteria-
—T e of Building
Other.fixtures
................................ .............................• -••- . •••---•--- •....••-••---•._......--
Desi n Flow.... .....................g ...............gallons per person per day. Total daily flow...........................................gal ' ;
W, ions
9 Septic Tank—Liquid'capacity_._.__.__.__gallons Length................ Width._................ Diameter................ Depth__.'.................
r Disposal Trench No Width__ _____________ Total Length.................... Total leaching area...................sq. ft. `?
3 Seepage Pit No............. ------- Diameter____________________ Depth below inlet:__._.: Total leaching area..................sq. ft.
Z:. Other Distribution bbx ( ) Dosing tank ( )
a'~ Percolation Test Results Performed by..........................................
--=----•-----------•-•---•-•---- Date........................................ ;
Test Pit No. 1................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..............:.........
D Description of Soil ` '�" `• ....---•---•-•-_•-•--••--....•••......
............•-•-•----......---•-
x
V -------------------------------------------------------------- =
W
U ,Nature of Repairs or Alterations—Answer when applicable___Xd'`�!""r!...... . .-- E ....:.... ....:..:
;;ate -------------------
...--•--•----------•--•----..._..•-•...................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TILT 1- ' 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b en issued ky the board of health.
Signet _
Date
Application Approved B "'`-:
PP PP Y _.....-•••-•-------•------••-_--•--- ........................................
Date
Application Disapproved for the following reasons:..............................................7 7.................................................................
..,� ..,
*� Date
PermitNo.:__ :. ...................••----------_._.. Issued_..................-•---------------•-------- --------
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
C.-4sr .
�rr�i�irtt#r ,af f�rrm�rlittttr�e
T I TO CEERTIFY, That the Individual Sewage Disposal System constructed or Repaired
InstIall°e
at........... C'----- ............................. -- --- °°"
has been installed in accordance with the provisions of TI T LF 5 of 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 GU RANTEE THAT THE
SYSTEM WILL YUNCYION SATISFACTORY. � G }
DATE.: .. ... - . Inspector......... ...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD,•OF HEALTH
�" ... No........ q FEE.................
fit t ea' t Murk valml utt Prmi
Permission is hereby granted . oc-e r - -•• --•--•-•-------•--•-•-••----•---......•---------------------•--...._••-•.._........_....
N» to Constr ( ) or Repair (L -fan I• ividual Seaag Di osal System
at No.... ------ •• ........... : fw.+ *
-----------•-----•-•-••-•--•••••••-_--
as shown on�the a lication for Disposal street
pp p Works P No... ........ ated......... _ � 71.....
IF" i Board o Health
'
DATE ......... ............
ft FORM 1255 HOBBS & WARREN, INC., PUBLISHER§ ¢.el" e
LO CAT LAN SEWAGE PERMIT NO.
/97
V LAGE
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INSTALL R'S NAINE b ADDRESS
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R DILDE R OR OWN ER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED �"/� 7 7
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