HomeMy WebLinkAbout0196 OLD COLONY ROAD - Health (2) Rl� 6WICOON 1�4
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1 THE COMMONWEALTH OF MASSACHUSETTS
BOARD ® HEALTH _
OF.......... - ...............
VVV
d �pphration -for 4%iVatial Worko Tooitrort'on Vrrmit
Application is hereby mad for a Permi o Construct ( ) or Repair ) a ndividual Sewage Disposal
ystem........... at: -
--------- /� • � •
Loca WA'Lr ess 'fr� orNo.
....... ----- -• '- ..... J............. ....... ........................... •----•-••----- .............................................
resess
Installer Address
Type of Buildipg", Size Lot----------------------------Sq. feet
U Dwelling( No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ------------------------------------------------------
W Design Flow__ ______....___________________ ______gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank Liquid capacit� allons Length---------------- Width................ Diameter---------------- Depth----------------
x Disposal Trench—NQ_ ____________________ Wi th-----------
*e �
l ength _ ___..; Total leaching area..._..__....._......sq. ft.
Seepage Pit No.----- ...... Diameter ..._ o �.:...... Total leaching area
t------------------sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed bY.......................................................................... Date................--••----------------._..
a
a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_..-----------.---------
G%, Test Pit No. 2....._----------minutes per inch epth of Tes Pit-------------------- Depth to ground water-_---.---__.-_.-----.._.
P4 --------------------- -----------------
•-------•-------------------------------------------------------------------------------------
0 Description of Soil-------------------------------- - - -- -- --------'•--- ----••---------•-•-------------•-••-------•----•---------•--•--•---•---------------
x
U _
W -------------------------------------------------------------------------------------------------------------------- - c
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 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 i sued by e board of he
igned__ ----- .........------------
Dat
Application Approved BY - � f-3.
Application Disapproved for the following reasons:...................................... •---••-•--:.................-•--------------•---------------......•-•---
..-•'•-'•--------•--------------'--.......'-'•------.....-----------------•-------•••--•--•-----------••------------------•-------•----------------------------------------'•----------•---•---•-.-•---
Date
PermitNo......................................................... Issued........................................................
Date
t�
..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O WEALTH
'. .. Aj
....:....OF............ �.
,�nnlirtttion -for 43itinoottl. Works Tutta��V) an
uu aeruid
Application is hereby mad for a Permi �to Construct ( ) or Repairt ndividual Sewage Disposal
System at: / ,q i ,.� �. U
---4AK
Loca Address or of No.
= ---- ------- --- - --------------- ------ --�------------------------------------------------------......----------------------....-----
---- --•--••--------------------------•------... Address -•----------------------------------------
Installer Address
Type of Buildin - Size Lot............................Sq. feet
U Dwelling�No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
44 Other—Type of Building ............................ No. of persons._--._.-_-._---___--__-___ Showers ( ) — Cafeteria ( )
Q' Other fixtures -------------------------------------------------------
W Design Flow--------------------------- __________ Mons per person per day. Total daily flow--_---_______-.-_-:--__---_-------...-------gallons.
WSeptic Tank I Liquid capaci ✓� allons Length................ Width.-__- ..- Diameter-------.-------- Depth_____-...._.
isposal Trench
en th
Total
eaching
SDeepage Pit No _' Diameter t __' a,_ i Wne - ---___ Totallleach gaarea..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by--------------------------------------------------------------------------- Date---------------------------------------
a Test Pit No. 1-----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water---------------------
f1 Test Pit No. 2----------------minutes per inch, epth of es Pit-------------------- Depth to ground water.._...-..-._--__-_-----
----•--- . ..........................................................................................
0 .
D Description of Soil----------------------------- '° - .......................... : .
c� : .
W -•------- ----- ----- -------------------- n--• ------------------- - 9--------- �_----Jj a
erg_/'J/J --- - --- -
U Nature of Repairs or Alterations—Answer when applicable._" -...._ ` � ' "�
---------------- -----. -- -� . . ,-4 ----- ----------- ---------------------------------------------------
--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 jssued by,the board of h541M.
--iSigned�, '�� '`a F - s' ......• •---•-...... '................................
b vp ' 9r Dat
Application Approved By--------
�;p: ate
> ,
Application Disapproved for the following reasons:----••---------•----------------•- ...........--•---••----•-----.------------------------------.
-,-•-------------•-----•----------------------------------------•---•---••--•-•-•-----------•---------- ------------ =-----------------f -------------------------- ----------
�r- -
„ ''LL c/ j'Permit No-----------=-----------------------------••••----........ Issued---!(� ------
'
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ,i F HEALTH
•�f ...:... . ...
Maertifiratr of 'T"Untphaurr
THIS IS TO CERTIFY, Th�t the Individual,Sewage,Disposal Sy&t= constructed ( ) or Repaired
by �'� i � `
staller "
at-----•-611, !"` �'�'/ �`"'r
has been IInIalled in accorda c with t'1�erovisions of Article XI of The State Sanitary Code as des ibed in the
application for Disposal Works Construction Permit No__________________: dated___.:°... _-------.
THE ISSUANCE OF THIS CERTIFICATE SHALE. NOT BE CONSTRUED AS A GUA.. ',ANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE `�^l� �:: Inspector. /---1.....e-Z--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O,F HEALTI�
f M .:,
No FEE----- .,,u.._...........
�i�:�o�tti orka� Cnu�t��rttr�ioat �rroti�
Permission is hereby.grant d---- ` "z.t'......... f`, ,, ``�;j" I--------------------------•-•-------••----•-----------•----
to Construct ) orRev'ir,( fan Iivldual Sewage Disposal System
at No 1_ . its ... -- ------ ....... j --------------
�:
Street t .MH f ,
as shown on the application for Disposal Works Construction r> t No .__ ,,Dated__: ._�,_.t'' see
A
,'�'" Bo of Health
DATE................
R J ' '",�' '" G <�. rr
or
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS