HomeMy WebLinkAbout0061 OLD SCHOOL HOUSE RD - Health (2) l01 Olds �F�wl h�¢, p�
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. .No- -------- FER.. ................
-------------- 9,210-9,
THE COMMONWEALTH OF MASSACHUSETTS
BOARD!o HEAL
\ , .. ..('} ` .......OF...................................
C)
5 ^ liraftart -fur Bi,ai weal narks Tontitrurtiaan rru it
pplication is hereby made for a Permit to. Construct (dam) or Repair ( ) an Individual Sewage Disposal
Sjpeof
at
P...
Locario Address e No
e
caner -_--- Address
_ '. ._ __.. .ls�i/`- ....................._._.'staI er Address
TBuildi�n$ —� Size Lot_.� �- ....Sq. feet
U Dwelling dZ No. of Bedrooms-------------- ............................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons_--------_-__-__-_-__---_- Showers ( ) — Cafeteria ( )
P4 Other fixtures .___.f----------------------------------------
W Design Flow ______________________ gallons per person per day. Total daily flow........_ ........gallons.
WSeptic Tank Liquid capacity gallons Length---------------- Width................ Diameter__......._.___ Depth__..______.___.
x Disposal Trench—No_ ____________________ Width...._..__ __ T ��Igg -.------____----__-- Total leaching area-.--.---____._.-:_--sq. ft.
f Diameter "`�D`e et_......_ Total leaching trea��
Seepage Pit No.-__-----/- �Q .____ _
gq. ft.
z Other Distribution box ( ) Dosing tank ( )
•-' Percolation Test Results Performed by-------------------------------------------------------------------------- Date------------------------------------
Test Pit No. 1----------------minutes per inch Depth of "Pest Pit_.--_--__________- Depth to ground water..--_---.--.--.-__-_--.
t% Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water_-_.-..--.._---_---.-.
a ---------• -------------- ........................-----------------------------------------------------------------------------------------------------------
0 Description of Soil------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------.
x
U ---------------•---•--•-----------------------------•-------•• ---------------------------------•---------•-----------------------------------------------------------------------•--.-----------------
W ----------------------------•-------------------------•------•----------------------------------------------------•---------•----------------------------------------------------------------------•---
VNature 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 NI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued y the board of health.
ed '"—•------
T D fe
Application Approved By..........:... �� ' .... 7----
� ate
1 -
Application Disapproved for the following reasons:............................ .............. ---------------------•-------------•-•----------
--•-••-•-•------•-••----••------•-•-•--------------------------------------•------•------•----•----------------------•----------------------------------------------------------------------------.-----
Date
Permit No. Issued .............
Date
r^y
F��.. ..................
THE COMMONWEALTH OF MASSACHUSETTS
4
BOARD HE T,L
;'_).......OF.............._..........................................................................
, pV1iration -fur Miipoiitt1 Workii Tomitrurtion .13rrui t
Application is hereby matte for a Permit to Construct (/) or Repair ( } an Individual Sewage Disposal
Syst ati/ ,
r Locatio ••Address * Na d9
qa,.�cys3�- ------ -------- ----------- ... f,<d`"v`�!3 d�; '7r/a�✓ #
-----------•----•----•--Address----•-----------------•--•-----------•-•-•-
- -------- ------
nst
weer
►Wa y y �`�
l eT r Address
T pe of Builditn� Size Lot..,_e�% •... .___Sq. feet
Dwelling; No. of Bedrooms--------- _______________________-__-Expansion Attic ( ) Garbage Grinder ( )
aOther•`=Type-of Building ____________________________ No. of persons.---------------------------- Showers ( ) = Cafeteria ( )
Q' Other fixtures ............. ............._---- _ _
db
W Design Flow____ _.___Egallons per person per day. Total daily flow.......
gallons.
-------------
WSeptic Tank 3-Liquid capacity/E &gallons Length_____ ______ Width ----- .. Diameter................ Depth_ .----- _. --
x Disposal Trench—No---------------------- Width; To,al Ig ____________,,_ _ Total leaching area..... ....sq. ft.
Seepage Pit No________ _________ Diameter '.`S .._. Dei ow t let......... ________ Total leaching area., . t._ q. ft.
Z Other Distribution box ( ) Dosing tank ( )
`-' Percolation Test Results f Performed b 4 Date__________________________--____-------
W Y -- ------------ --
,� Test Pit No. 1________________minutes per inch Depth of "lest Pit-------_ ---- Depth to'ground water._--.--.-._-.-_-.--.--
(_, Test Pit No. 2________________minutes per inch Depth of Test Pit---------............ Depth to ground water--------------------
---------------------------------------------------------------------------------------------------------------------=---------------------------------------
D Description of Soil----------------------------------------------- .k
x
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 agrees not to place the system in
operation until a Certificate of Compliance has been issuey the board of health
Signed. t - - �* � `°'-----------
Date
ApplicationApproved By............................ ---'--1'-------------------------------------------------------------
• Date
a
Application Disapproved.for the following reasons---------------------------------------------------------------------------------------------•_----____--_-------
--•---....----•-•-•----------------'=-•-----------------------•--•-•••----------------............................. -•--•----••-•-•---•------------------••-••-•-•----•--•---------------•-----------
Date
PermitNo......... ............................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD QF HEALTH
40 ,
; .
..................' .......¢` .....OF........
. . -°t�...... ....
Qrrtifiratr of fVklamttattrr
S IS O TIF. That the ndividual isposal System constructed ( or Repaired ( )
by...... 1 -- - -- ------ ----- --------------------------- ----------- ------
/ tal r
--at - y1J t--
has been installed in accordance with the provisions of Article XI of - hem(State Sanitary Code s des *bed in the
application for Disposal Works Construction Permit No------------- _ ._ _L ______. dated....... _._ / .. ..
1' ` /
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS ED AS " .0 RANTEE THAT THE
SYSTEM WILL UNCTIO 5 TISFACTORY. ��,
.DATE--------•- -� ---------- ------- ........................... Inspector----------- -- `-- -..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
44 ............. e� =.4 OF. �..;� � ... J ..--•---.................7
.... r'
No. ••••••--•-•-. �. FEE--- _=• .............
Bi_Vo Il�xk trttrti�tt rr
Permission is ereby anted.... �$! ,
".
to Construct 1
r,------ - ( ) n Indiv, ual ag isposal System
rt
1.............
-. Street
as shown on the application for Disposal Works Construction it N 4.ad
Dated___. _ _a____.
, T"'t
H' _
th
Heal
DATE__ --.? :'._ /y ry
+ FORM 1255 HOBBS A WARREN. INC.. PUBLISHERS
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