HomeMy WebLinkAbout0012 OLD SCHOOL HOUSE RD - Health pr/
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THE COMMONWEALTH Or MASSACHUSETTS
BOAR® F HFAL
_... .......... ®F..... .................. ......... ---------
Appltrativit for igitivvoal Workii TowitrlY.l` inu ramit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
system _ .........1.... f ......... ............ _.-:
1 cation• dress /' Lot No.
.{. ........... .... . ......�..... ........
........
...........
.....
.....
-Owner E ll,ay.1Of kv`�J . Address
.... ti. ..,�. Installer G . !rJ iy/1E......<...... .. ...............Address......s....��..// .//.........-............
U Type of Building Size Lot...'7.._"7.___•-l..........Sq. feet
Dwelling T No. of Bedrooms..............e....;f�_..••-.._..__._-__Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons............................ Showers — Cafeteria
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� Design Flow..!-----•--------------��........gallons per person per------------------------------------•------•---------•---------------------------•----•--------
Other fixtures _____________
,�,, day. Total daily flow...............=...A- 'Z........gallons.
� Septic 'Tank—Liquid capacityl•ff_� gallons Length................ Width................ Diameter................ Depth......_-_-------
x Disposal Trench—No_ ____________________ WA id . _.___ -Total t h-_- ----__ Total leaching area....................sq. ft.
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Seepage Pit No.._-/______________ Diameter.�_th�.-�V-_._ b ow in e ..-....-___._______ Total leaching area_- 1�.. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Restk s Performed by.......................................................................... Date........................................
Test Pit No. l... minutes per inert Depth of Test Pit.................... Depth to ground water------_------_----_-----
�, Test Pit No. 2..............__minutes er inch Depth of Test Pit.................... Depth to ground water........................
................. ........•-----••_-__-_ ................................................................................................................
0 Description of Soil.............. - __
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 Article XI of the State Sanitary Code—The undersigned further rees not to pla•e the system in
operation until a Certificate of Compliance has been i d by e board of -�
SignedL--• .- • --- -- .......................
Date
Application Approved By..... .. ....... ...........
-= -•--•-----
ate
Application Disapproved for the following reasons:--------------------------------- _---•-----------------
..........•••••............................................................................-...........................................................................................................
Date
PermitNo.•-••••••-•............................................. Issued........................................................
Date
FEE. ,... �"
1 THE COMMONWEALTH OF MASSACHUSETTS
BOARD PF H EA!_-
. OF ... .... .... -.-.-...-
Applilafflon for 3i p lial- 1 '.divTou'Ar trfinY� !*Utit
Application.is hereby made for a Permit to Construct ( )' or Repair ( ) an Individual Sewage Disposal
....System.
_
X9 E
cation- ddress y Lot N� w
Owner Address
W4,4,4. ....:.................................
Installer - _ Address f
d Type of Building Size Lot _.,.....Sq. feet
Dwelling :'IVo:cf Bedrooms ______________Expansion Attic ( ) Garbage Grinder ( )
pa, Other—Type of Building ............................. No. of persons__. ,_-..................... Showers ( _-) Cafeteria ( )
Q' Other. fixtures
........................................... ......................................... .................
W Design Flow ::............:.. ,_gallons per`person per day., Total daily flow _._ ___gallons.
W Septic Tank 'Liquid capacity allons Length _.. Width. .. Diameter Deptli
` x Disposal Trench—No Width Total ngthAo Total-leaching'area `_ sq ;ft.
s ����Seepage Pit.No---- ______ Diameter. ....__ ept ow an et Total leaching area
Z Other Distribution box:,,( -;) Dosing.tank_
Percolation Test Res 'Performed Date________________
Test.Pit'No. ______________minutes per inch Depth of,Test Pit_ - Depth to ground water. ______-
�T, Test Pit No. 2................minutes per 'inch, Depth of°.,T(!A Pit_ Depth :to ground water_
O - - =
Description of Soil -_ :y�r'" '+ - ----- ------ -------------------------- --------- ..................
x ,.
V - ........................ •••••--••-----•-- - --•-- ••••____________________
W ,,
UNature of Repairs or Alterations=Answer, when applicable, ................................__________________________:_.___.._..._..
Agreement,:
The undersigned:-agrees to install the aforedescribed:, hidividual-Sewage Disposal System in accordance with
the provisions of'Article XI,of'the State SanitaFy,Code—The undersigned:further ees notio plaee'the,systetn'in
operation,until a Certifieate of,Conipl ance;'h been, is ed by eglioard-of h •th. �-
r F�
Signed
Date
A lication A roved B C
PP PP Y •--•• �r
J.., ate
Application Disapproved,for V f. 11 zviw reasons:_- ,__-- •:_--__ ______ ________________________________:.._........
..-- -•••-•--•-••-••••••----•............................... ---------------------------------------------------------
Date
PermitNo________________.......................'_+ _ Issued........................................................
Date
THELCOMMONWEALTH OF MASSACHUSETTS '
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T lIS TO CL� T FY, That the I11ChVldual Sewage Disposal System constructed (�or Repaired ( )
L XA^Itoo
at < -' .:A+ ._..._.. - ----.X"�W. dam`:
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has been-insta'll:ed,in accordance with the Provisions of;Article Xh of The State Sanitary ode. de,de c ed in the
application for Disposal Works Construction Permit No_____ __;�` ..dated ,� , s_* _ r.:
THE'ASSUANCE>,OF THIS CERTIFICATE SHALL N®T Bt,66N' STRUE,D.AS A �UARA TEE THAT THE
SYSTEM WILL F C49 N SATISFACTORY °�C
DATE..•- �� 7 :.
-_._•. •• Inspector .. .,-
THE CO�"A'MONWEALT.Fl-.Or 'MASSACHUS:ETTS "
.� B;OAR0 OF ",HEA T
NO ;` FEE ..............
tit Srl1li �•~ ��� VY' 44 e, x`6,. �iii.• . r,
Periniss>on is ereby granted 1
r �
,-
._ .. ........
to Cos ct o Repa r '( rrIn id u 5'ewa D 15os�1 Syste ,`
, ._. ,• - : Street # r t � ,c
as shown on the application for.Disposal `,L'orl.� Coiistluc�ioti Pe iut lVo:. _y I?ated
oa,d� F-II al ,
DATE
FORM 1255 HOSBS-& WARREN,.. INC PU LiSH,ER$