HomeMy WebLinkAbout0136 OLD MILL ROAD - Health ad _
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LOCATION SEWAGE PERMIT NO.
VILLAGE
wi 69IeS 77) -s Ic i
INSTA LLER'S NAME 6 ADDRESS
L/. F 422 Z/A--d o 5
BUILDER OR OWNER
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DATE PERMIT ISSUED
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DAT E COMPLIANCE ISSUEDfl/J
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33
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF. HEALTH
.... .......
........oF... cs.....................
Appliration for Disposal Works C oustrurtion Prratit
Application is hereby made for a Permit to Construct (V5 or Repair ( ) an Individual Sewage Disposal
System at:
............. ...� \\ ------�- -....--------..---.....---...................----••------•-------..........------.
r L cation-Ad s
or Lot No.
W \� e � Owner ,,5
,� ............................ ...................................... r n. .-----------.....•--....._............•---
14 Installer Address
V Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............ .............................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons.....--..---................ Showers ( ) — Cafeteria ( )
Otherfixtures -------------------------------•----------------•---......----------------•-----------......------.....-----------------------.....------------------.
W Design Flow............. ®.....................gallons per person per day. Total daily flow.._...._-c�--.------..-............gallons.
WSeptic Tank—Liquid capacit.k ..gallons Length................ Width................ Diameter................ Depth................
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 ( ) Dosin , �n�k
`-' Percolation Test Results Performed by......\5C ._ ....__ ._._l."` ....._ Date.... .:� ..........
a
Test Pit No. 1................minutes per inch Depth of Test Pit......--............ Depth to ground water......------..--..-----.
4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to.ground water.-----..................
a ------------ -----------------------------
O Description of Soil...... ... .cap ....._? Sv _.��. ------
------------------------•---.---•---------.-.-.----
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 TIli LE 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.
ign - - ------------- ]---------
11 p
�atr
... . ..... --Application Approved BY � . .............
Date
Application Disapproved for following reasons--------------------------------------------------------------------------------------------------------------
----------------------•----••-----•-------•----------------...------------------..............•---------
Date
PermitNo......................................................... Issued....----------...-----------
I .......................................................
Date
3�r
11
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
f ...............OF... �r.'ox�l
------------------•-••.........
ApplirFa#ion for DispQiial Workii Tatui rurtinat V.rrutff
Application is hereby made for a Permit to Construct (V� or Repair ( ) an Individual Sewage Disposal
System at y
............. s r.....�!... 1 .....� .....�_ `d
Location-Address or t No.
`ate 1�t1f:S_........ ti � ..... �1?. -tP. ' �._` : :' �..... ......................_..
Owner •e 1 Address
W `a .:_( � ��l .>> .�A Art s � lam��,\t;_
---••-. -- --- ----------• .......... ......--`...._.I..................................................................
Installer Address
Q Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............. .............................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No, of persons............_................ Showers ( ) — Cafeteria ( )
G4 Other fixtures -----•--••-----•--•---•--•-•-••. -
W Design Flow.............. .....................gallons per person per day. Total daily flow........:-2........................gallons.
04 Septic
x Disposal Trench Liq No capacit)...�`` dthns Length Total Lengthidth................
.............Total leaching area...Depth.......sq. ft.
W �I
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing:tank ( )
Percolation Test Results Performed by......�K*--` __ �- �_..._---- I- " '........ '
W - Date .. ..-- -"�
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.....................
(s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
x •_" ----- ..c"----t---�---
�-t -
Description of Soil " �- ----T-------------.....---.. - !�'�-2 "U ••-•-•-----•--------------------C..---st- ... "'Ll .- ...........(..-'
W
UNature 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 T I T U 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.
igned 1 _rv^; � t . 'Vlf�n �!tr i.? �` ij 3
r (_1 DDate 2
ApplicationApproved By--••-••... .... .•• •------------------------------------------------•------------ .....#-'.. ......... __2......
Date
Application Disapproved f o t e following reasons-------------------------------•-----•---------------------------------------------------------------------•----
---------------•-------------........._........_....--------------•-••••.....---------._......----------......••••-••--•--••--•••--•-••••-----•-•------.................................................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
1 ..1.3�..................OF..........\'}(J (l S.`. ... . A.
.....................
C9rdif iratr laf Tvrmpli attrr
T 'IS S TO CERTIFY,: =hat the Individual Sewage Disposal System constructed � or Repaired ( )
by------ �=--�---------------- r--.._._._ ---='5.---s-----------------------------------------------------------------------------------------------------------------•--------.-._
Installer
at....---•,�5='--�---------- `'' -------- `\_�--......_... ... _a' 2)•:,--. \1..
has been installed in accordance with the provisions of TITIZ 5 of The State Sanitary Co described in the
application for Disposal Works Construction Permit No... .............. dated_-d ., ..........................
THE ISSUANC OF THIS CERTIFICATE SHALL NOT BE/CON/STRAS A GUARANTEE THAT THE
SYSTEM W _TION SATISFACTORY.
DATE.... ....----------.........---•--••-•.........._•-•-•. Inspector ----------------•------...............-•----••--•-•-----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No.lf lc`!�•"'...............OF
..............R`.....(!... ......... •.........-•...........--......... FEE.
. _
Big os al Vfh_�T.1tt atr wtt mitt,
Permission is reby granted--••. .' i ,1 ``'
to Construct ( `' _lor Re it ( ) an Individual Sewage Dispo al System
Street
as shown on th;eappli on for Disposal Works Construction Permit Nfe_J _._ Da ... ...........................
_________________________yj ___-_ .............................................
"7 y Board of/Health
DATE -••y-- ..--.-. ..-/--------------------------•-------------_-.....
p FORM I 5 HOBBS & WARREN, INC., PUBLISHERS
t
I SIuGLq,-a FAMIL.Y BEORQoM l 41 . SZ
FJU GARBAGE �jWNDE2 / � y
DAit- ( FLOW z 110 A 3 x 3306.PCI
5E.PTIG TA►JK = 330x15o%
o L o-r 14
U5� 10o GAL. � , .,
0ISP03AL PIT V'5 1000 GAL.
5 1 pr-WALL AREA• = 15a s•F, c AF
150 5.1= X .2.5 r 3?5 G.P q s�arA I
BOTTOM AQF-A 0 6.F
5O 5.F x I• o •o G.P oY i
-TOTAL- D1=SIGN q25 G.PD. �/66.b
-foTAL pA%LY FLOW 330C.P0 f i `
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DAT E S Z7 83
F3AXTEe� NYE INC.
' REG I SZ�5�6•U'LAu o 5 v�v EYoes
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"Iw'57-?-uMENT SueV Y �--TNE OFF5ET5 6uouLS>
NOT Dlr "U55.0TO De7F-F1\1►-1G APPLICA►J r �MCS l� . . S✓YIiT?-�