HomeMy WebLinkAbout0091 OLD TOLL ROAD - Health 91 • 1 TOLL ROAD
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LOCATION WAGE E W PERMIT .
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INSTALL R'S NAME ADDR SS r
3UILDER OR O NER
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DATE PERMIT ISSUED qe-D3-7`(
DATE COMPLIANCE ISSUED y
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No.............. .. T .. Fin$..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
b� T / ...............oF.. ......... ... . . ....................................
Appliration for Dtspuiial Works Toustriirtiun rrmit
Application is hereby made for a Permit to Construct ( /or Repair ( ) an Individual Sewage Disposal
System at
..... J.. p�.. � --•--•......•••• --....: _ ..........................................................
.... .. =.L0 ...... Addr s -•----------••---... SCE. . --------- Lot No.... .......d�v 4
Owner • Address
W
� Installer Address
Type of Bu' ding Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms____4-_______________________ _____Expansion Attic ( ) Garbage Grinder
~ Other—Type T e of Building ____________________________ No. of ersons________________.___________ Showers —
yp g p ( ) Cafeteria ( )
Q' Other fixt es --------------------------------
W Design Flow __.:: _____________________________gallons per person per day. Total daily flow...................�- ..................gallons.
WSeptic Tank ___Liquid capacitySbO.gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No_ ____________________ Width.................... Total Length........ Total leaching area....................sq. ft.
Seepage Pit No... ______________ Diameter_._..1.R....... Depth below inlet...... Total leaching area..................sq. ft.
Z Other Distribution box ( V - Dosing tank ( )
'.� 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................n inute per inch Depth of Test Pit.................... Depth to ground water........................
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ODescription of Soil........................................................................................................................................................................
x
U
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 TI IL 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 bo rd of 1 ealth.
Signedh '�? •� !.. ----..._-•••-- d' a `r
`T-
Date
ApplicationApproved By.................................................................................................. •--................-- .--..............
Date
Application Disapproved for the following reasons----------------------------••----------•----------------------•---------------------...-----------•--....------
--.........-•-•----•------_--•----•------------------------•--••-••••-•---------•-•......------_._..._.....
Date
Permit No.............•---••--•-•-__-•• - 7-. Issued.... .�-- ----------------------
Date
No....... .. Fus.`........................... _
THE COMM' ONWEALTH OF MASSACHUSETTS
D OF HEALTH BOA.,
l
o...... ..
Apphration for Dhipasal Works Tonstrurtion ramit
Application is hereby made for a Permit to Construct ,( or Repair ( ) an Individual Sewage Disposal
System ;it:
Lo' Addr s Lot No
,. /
Owner Address
W
€ ................................................
Installer Address
Type of B ding Size Lot............................Sq. feet
)., Dwelling—No. of Bedrooms._. Expansion Attic ( ) Garbage Grinder
aOther—Type of Building _____________•_•_...____...- No. of persons............................ Showers ( ) — Cafeteria
04 Other, x res .............•-•-•---- •------• .
W Design Flow '_: .....:.gallons per person per day. Total daily flow__._ ......................................gallons
W Septic Tank L Liquids'"rapacity/. .gallons LengthTotal Length al leaching area_-_Depth.---... ft.
a
x Disposal Trench—No................... Width• _ g i/ g q.
Seepage Pit No.--.A-------------- Diameter.._..I.;........ Depth below inlet......k ......•.. Total leaching area..................sq. ft.
Z Other Distribution box (Vor 4Dosing tank ( )
Percolation Test Results Performed bY................. ........................................................ Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit..........---------- Depth to ground water........................
f� Test Pit No, 2..... ._..�hii�,hs per inch Depth of Test Pit................•.•. Depth to ground water..........................
ODescription of Soil =-••-_.....-•-...-•----••••-•--••-•--•-••-•......•••••-•----•-•••-••----•••--••••••--•---••••-----•-•-•--••-........-•-•----••.---•-
:.
W ----•--------------• ----------------------- ,................................................. ................................................................................................
V Nature of Repairs or Alterations—Answer when,atVica.ble.........................:.....................................................................
._ ..•--...
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIa� 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of pli Cofnance has been issued by the bo rd of ealth
Signed---- .............• •--•-•
Date
Application Approved BY -------------------------•-•------.---•..-•-------•-----.---•-•••--==----
••----..._.............................
�,r''1 Date
Application Disapproved for the following reasons:---._...---•-•......•--.--•--.. -••-•...--•-•-••-•--...---•••••-----------•-••--•-•-----•••-•••---------------
f
Date
Permit.No.......................................................... �• Issued.......................................................
: .. -.+.• ++ " Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9V HEALTH
..OF..
Trr#ifiratr of Tuntplianrr
S ISrT t she Individual Sewage Disposal System constructed ( IIT or Repaired...( )
by.....: : f................ - ---- ----------- -- --------------------------- = l
Installer ,
at.._. �• ............... .f
has been installed in accordance with the provisions of T j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No. _... l .. 'fs............. dated--.. *'__ _ .........
TH,E :ISSUANCE OF THIS .CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE -.
SYSTEM WILL FUNCTION SATISFACTORY."7
DATE.................................... ......................................... Inspector......----............-----•-•--------------.......................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
,r� OF........... ... ... ... ................................. �
UiS rvff orks �11mi io rrntit :
to Construct
' eby granted_..... ' � .....,.. � .....
( r `pair ( ) dividual S714, Dis al
at No.
'.__. 7 _ "'.h . , Gf.fl.F�IG
4-1
...
Street
as shown on the application for Disposal Works Construction Per No. ated.. .'" ...'�4 .......•If----------
t ` Boar of Hcealth
1M
DATE.. qO •;:, .7 ................................................
.;
FORM 1255 HOBBS &WARREN, INC.. PUBLISHERS
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