HomeMy WebLinkAbout0044 DEER HOLLOW ROAD - Health-rj� C
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PARCEL NO.: ®
TILLAGE
INSTp LLER'S NAME ADDRZSS
Elil_ DE R OR OWNER
SATE PERMIT ISSU10
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[9A-T—E COMPLIANCE ISSUED
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH '
......7w w/Y .......OF.... 3.f t .N...�S'.�" L --------------------------
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Appliration for 13iiposal Worko Towitrur#ion Vanfil
Application is hereby made for a Permit to Construct (,- ) or Repair ( ) aji Individual Sewage Disposal
System at: !�
o�Lo Gv ? Y 6M /LL
....................................--•••�'':�-.-...
Location-Address i or Lot No
. ,�,_r.._..., a •_ �� ... ' ------•-•-------
W Owner %7,�i(/L� Address
i
.... .._ _ ................ .. .. _ ...a._.._.._... _..._ --__•__ L :. .._.._ �. '!L. .. . ..
0.l
Installer Address
Type of Buildin Size.Lot-
,3__7_7—e(2_....Sq. feet
Dwelling No. of Bedrooms___- 3.. ..............................Expansion Attic ( ) Garbage Grinder ( )
p., Other—Type of Building ............................ No. of persons..... ------------------- Showers (a) — Cafeteria ( )
Q' Other fixture
-- ------•----•---------------------------------------------------•-----------------------------------------------------.--
W Design Flow ................ _.__L__----• gallons per person per day. Total daily flow........... _._L gallons.
WSeptic Tank-Liquid capacity gallons Length................ Width................ Diameter................ Depth---__-_-____-...
x Disposal Trench—�°..................... Width......_......#e-p
n h_._..___.___._-.____ Total leaching area....................sq. ft.
Seepage Pit No.____--f--_________ Diameter/ --�, w let.................. 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---.._-__-__-____._._---
0� Test Pit No. 2................minutes per inch Depth of Test Pit.....................Depth to ground water--------_---__-_--__.._.
O
-- --- .......Description of Soil............................................-�--- ----- -----•--- - ---- -------- - - - - - --........-----------------
-
W ------------------------ /------------------------------------------------ . . . ---=� ----- ---
UNature of Repairs or Alterations—Answer when applicable......�4161w- --_______________________________________________________________________.
-----------------------------------------------------------------------------------------------•-------------------------------------------------------------------------------------------------------.
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 been issued by the board of health.
igned... •• .... • -Ce. . ��=``� ------- /f'7T
,/� Date
Application Approved By------- ------
ate
Application Disapproved for the following reasons:........................................... - ----- --------•---••---------------------------- ...---•.......
Date
PermitNo......................................................... Issued........................................................
Date
------------------- '-'-----�------ .-_-
No.... .... FEI�.. ... ..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
ro W y --'- _OF.... A.17,1Y -.7--"" - 4. .................... ...
App' iratiun'fear Diapnsttl Works Tome rnrtivn Prrmit
Application is hereby made for a Permit to Construct O or Repair` ( ) aw Individual Sewage. Disposal
System at: '; d -"`7 2-11
L+ a' Address y _ / or Lot N
Owner Ad ress _
..---
� Installer '� Address
UType of Build Size .....Sq. feet
.- Dwelling No. of Bedrooms.-_.._.-..yam___________________________ ......Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons_____Z................... Showers (,) — Cafeteria ( )
Other fixture _
W Design Flow________________ ____ ___ gallons per person per day. Total daily flow.______ " _gallons.
WSeptic Tank Liquid capacity _gallons Length................ Width---------_ ..... Diameter ____ -________ Depth----------------
x Disposal Trench o __________________ Width___ Ap
t en h.__________._.______ Total.leaching arel_.._.__.._.__.______sq. ft.
Seepage Pit No ___.__.__ Diameter lets___________________ Total leaching area------------------sq. ft.
Z Other Distribution'box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date-------------------------------------
Test PitNo. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-_-____-___.___-___.---
L� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_______________________-
--------------------------------=' ---------------------•--------------
Description of Soil.......................................... ....u. _ _ ---------- --- W
x
U ----------------------------- --------------------------------------------- ------ram- ......... -- --- .. -- - -- -- ----------.....------------------------------.
W
VNature of Repairs or Alterations—Answera when applicable.-'.._,/Y` �✓________________________________________________________________________
�
z .-
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 been issued by the board of health.
Signed--- -•- =•-•-- '-- !- , 1�-te
.................... --------
j ate
Application Approved BY �.....--- ----- {
Application Disapproved for the following reasons-............................................
-..................................................................
-'---•-••-•--'-----------------------------------------------------•----.....••---•--....._..------••---'
Date
PermitNo......................................................... Issued.................................=-----•-•-...........
Date
_ 4
THE COMMONWEALTH OF*MASSACHUSETTS
BOARD F HEAL,T:
.... ...: i -...............OF..... ...:..... ! .. ... :. .... y......
Try--firatr of Tnntplianrr ��✓'�
THIS IS TO CE IFY, Tha e Indivitual Sewage Disposal System constructed 4) or Repaired ( )
by - ••--........ -
t Inst er
at..... S __ r /
has been installed in acc rdance with the provisions of Article XI of The�.tate Sanitary Code s d clibediv the
} application for Disposal Works Construction Permit No.___..--•-. _ _._.__.____ dated _ e`_ . ..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT T�(
I SYSTEM WILL FUNCTION SATISFACTORY. �`
1
•'" -DATE-----••-----•. ......................... Inspector--------,
THE COMMONWEALTH OF MASSAC USETTS
BOARD 'OF HEAL
ter '
o ... ' --- '......... OF
N
%iPwial, orkii, ,itrttrtinn rrntit
Permission iv)
granted.____:__.___.... ----- W ?.L-lifQ----------------------------------------------
to Construct iv) or Repair ( an I vl I Sewn e DisposW System
at NO.: !L $ __,s .'"" ._ .1 + r t -- E
Street
as shown on the application for Disposal Works Construction Pe iit No __: -r Dated .............
Boar!
Health i
DATE......................................... ......................................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
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