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HomeMy WebLinkAbout0074 BLANID ROAD - Health ��mit A �t OA �&�v THE COMMONWEALTH OF MASSACKUSEYTS ARD OF HEALTH Application is hereby made for a Permit to Construct (b_�or Repair an Individual Sewage Disposal System at: Idd,es or Lot No. Owner Address Installer Address Z Other Distribution box ��e Dosing tank ( ) The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TTILE 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. Application Approved By............ ...... ----- ........... —, Date Application Disapproved for the following reasons:................................................................................................................. ----'---'--'--'---- - ----------------------'----------------'---'-------'—�Da t e------- | Permit Date i N L ��� ` THE COMMONWEALTH OF MASSACHUSETTS �l -- A RD OF HEALTH =/ Z)C.,A)rj 'f t Appliratinn for M-4voaal Works Touttrurtinn Prrmit Application is hereby made for a Permit to Construct (I1�or Repair ( ) an Individual Sewage Disposal System at: ,+� _ .............. --- -----....J_.. ...... ems. ...._....._���r..���.,./..--•- ��-t•J-'?- -"--r�------�-.�.a/-f- Location-Address or Lot No. .......... 1�..................... ...............c...... --'---.....---..........--•-•--------------- .•................. W Owner Address ..%> :J ...•......._C✓ .. ..r �,L: -�=-----•�------�--------------- --.plc.:.---- _ r.:: C . .�--=----------------.....-------...-----....-------- Installer Address r� Q Type of Buildin Size Lot ._ . _••-----_Sq. feet U Dwellin No, of Bedrooms.__....._ ._.___.._ Expansion Attic Garbage Grinder t j Pk Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------------------- Desi n Flow........... ...gallons n per day. Total daily flow....... . 4.n?......................gallons. W g -�G' g �� / 9 Septic Tank—Liquid capacity])4a.gallons Diameter................ Depth'__�_...y Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......I---------eiameter.j_-2_.-'.,.c..... Depth below inlet...l.!.......... Total leaching area'V.0......sq. ft. z Other Distribution box Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date------•-------•-••-------•---•-•------ ,� Test Pit No. I________________minutes per inch Depth of Test Pit.................... Depth to ground water......................... (z, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -------•......................•-----••--------•--•-•-•--............------------••............--•--•......................................................... D Description of Soil------C. ae=`----•-•--- ........L-"�- _"o---------- / `.; I�t'1 ''' ' x V ...-•-•----•---••--•----------•----------------•--••-•----..........................---------•--•--•-------••--•-----••-••-•--•-••-•••----.......•--•------••--•••------••--•-----•--•-•••-------••...... W -----------------------------------------------------------------------------••- --------•----•-•---------••--•-•---•......---•--•-•••---•- U Nature of Repairs or Alterations—Answer when applicable.-_____.-`?KL Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TT`�'+:! ;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. Signed--- -,, . Date Application Approved BY - --------------------- .......'j-, ial5iy ----•---- APPlieation Disapproved for the following reasons:............•----•-------•-••-•-----------------------------•--------------------------------------.........•--- ----•-----•--------------------------------------------------•-------•-•--•-•------------...------------.._......_........--------•--------•--------------------•-- == == Data PermitNo. ...... ....................... Issued-------------•••------•.....-••------------••--- Daze THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH D..V, ...................OF........l wr. ............................................... Tntif iratr of Toutplittnre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) bY-------•------_- - -L. .ez .. a. ........ P - ""' Installer - 'has been installed in accordance with the provisions of T i T iE j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..� ----�:�'7.. dated_....-.�'-�.��_l_��>:w.............. THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTIO SATISFACTORY. —.— DATE..............................�..../..2= 7..................... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ✓' cl r1� .. ,R, ..............OF........... ,-�- - '7t , ..... .......... FEE -. .......... at Works Tnngtrurtion prrmff Permission is here �epgair r nted..w -`- .....................................��.,............................. to Construct ( ) or ( pp)��a��n Individual Sewage Disposal System +-}1 at NC....... — �• \L:)�-------�--`a..... ........................................................ eet--•-- ..'.s... ---_.........................•-•••-�--•------•---•--•--- I as shown on the application for Disposal Works Construction Permit Dated..... L' ? '''� Board of Health r FORM 1255 HOBBS & WARREN, INC., PUBLISHERS i . ASSESSOR'S MAP N0. 9 77PARCEL - LOCATION SEWAGE PERMIT NO. VILLAGE olexll�l vl 5 qc INSTALL It'S NAME ADDRESS B U I LD E R OR OW ER ,al DATE PERMIT ISSUED a DATE COMPLIANCE . ISSUED /� � G • � ti 0 ro GV p y >. , .. , "+4 .. .'. ,.- ,. :. k,_ , a::,•.. as ..r,., `^are .a•- . 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