HomeMy WebLinkAbout0069 OLD TOWN ROAD - Health (2) Pb
No...... ..... Fn$.. .......
" THE COMMONWEALTH OF MASSACHUSETTS
_- BOARD OF HEALTH
-.....OF...... ..................... . . ------ -- -------------------------
Appliration for Vasal 15orho Tongtrurtion Urrmit
Application is hereby made for a Permit`'to Construct ( ) or Repair ( an ndividual Sewage Disposal
t
System� ^ .................. ......:.......... ...... ------------•................... ..... ------
L tion-Addres�j./ or Lot No.
.. � � ...... ....-•--.---- - --
- ------- ---•- •----•---
I
Address:....--... -•..-•-•-.-----.•-•........................
auer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures ............................... ..
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.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter..........--.------. Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date.........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..................-----.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.------_-------------.
a+' --------------------------------••--------------------------------------------•-••----••-•----- -•------------------------------------------------------•--
ODescription of Soil........................................................................................................................................................................
V ..........................................•--••----•----•-••••••-•-•--••--.....-•--------------••--•--•-••--•.......••••-•--•---•--•--••---•--•--••------•-•••••-•-•-•--•------•---•••--•--•..........•.
W ....................................................................................................... --------- -----••--••-•.
U Natr-e of Rep 'rs or Al rations—Answer when a pli ble.__- _°-,,fLg6`l�--_- :_ ........ ..........
-- --------
Agreement:
The un igned 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 bea"sued b- th board of l',gal
Signed -? ...�. '`` .........._ -...? •--
< Date
Application Approved BY-••-�
Date
Application Disapproved for the following reasons:................................................................................................................
...........................................................•----•---•---•-•--......-•--••---------------••-•-••-•-••--•-•-•-••-•-•-----••-•-------••-••-•••-•.........................................
Date
Permit No. 3 .. Issued..... °�.�- `�
----
Date
No......................... FEE mps... ........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
—A. A
..........OF..... .........................
Apphration for Diapood Works Tonotrurtion thrmit
Appri- tiori is hereby made for a Permit to Construct or Repair (J0T'a*"n*1ndividu. a1 Sewage Disposal
System ".t-. ... .:... ........ .....................
wa : ,' ' � ... .. O n _. -
...........................................
+. -o-. Lot N
r 0
L ton-Address
::IPK . ..... .... ...........
--------------- ___
------........-- --------------------------------------------------------------------------------------------------
1 p 6 Address
.7i �........... .................................................................................................
staller Address
Type of Building S-ize Lot____________________........Sq. feet
U Dwelling—No. of Bedrooms__________________________________.I..........Expansion Attic Garbage Grinder ( )
Other—Type of Building ................... No. of persons_._...;_______._.________.___ Showers Cafeteria ( )
P4Other fixtures .................................................. .............................................................................................
Design Flow............................................gallons-per person per day. Total daily flow............................................gallons.
Septic Tank—Liquid capacity.............gallons Lerig'th...........I_ Width..............:. Diameter....:-- 'Depth................
Disposal Trench—No_.................... -Width.......... --- Total Length..................... Total leaching .........sq. ft.
Seepage Pit No_____________________ iamiter--------------------- 13 pth-below.inlet.*.................... Total leaching area..... ...........sq. ft.
Other Distribution box Dosing z tank
Percolation Test Results Performed by-------------
-------- --------------_...................I..................... Date________-__:___.........................
Test Pit No. 1----------------minutes per inch Depth of Test Pit__.________.__...___ Depth to ground water........................
prq Test Pit No. 2................minutes per inch Depth of Test Pit._._.____________.._ Depth to, ground water______.____._____._._._.
04 .......................................................................................................--------------------------7------------------------
0 Description of Soil..........................................................................................................................................................................
........................................................................................................................................................................................................
U
................................................................................................................ ----- .............A----- -----------------------------------------
terations— bl ..........
U Nat*e of Re ir or Al Answer when a ........
r
..4.4 .. ... ..... ..... ..V........... .................................. .............................6.7
�p
Agreement:
The unY, igned 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 beoft'llsued by t1w board of bCalt!��'
Signed
......
Date
.................................Application Approved By.... ...................................................I........................... i......
t Date
.....Application Disapproved for the following reasons:----------------------------------- ..............................
.............................. ...
j
.............................................................. ----------- -------------------------------------------------------------------------------- ----------------------------------
'Date
PermitNo.__.. .. ....................................... a.. 2...........................
Date
.--,HE COMMONWEALTH OF MASSACHUSETTS '#4
BOARD OF HEALTH
.............. 0 <............................................
' a THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
by.................. ........ .........................................................................................
Installer
at................. ...... .......... .'.. ......A
........../ ....... �OF4 ..awt 2' ---------------------------------
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
j�l dated_____for Disposal Works'Construction errint V o. ----------------------------- 'I
11 - , L j- ---/w' ------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A G'OARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......... ...... .•........................... Inspector....z..).-,...a:.
--- --------------------------- .......
`THE COMMONWEALTH.OF MASSACHUSETTS
BOARD 'OF' HEALTH
k k.
........... .............0 F .............................................
No......ro
14spoal Workii Towitrurtion ramit
Permission is hereby granted._._.-......_... ...... .................................................................
to Construct or Repair an Individual
Sewa7. Dispo al stem
at No..........&.q....... ......... . . .....AC. 4..7...
................................................
Ye;ihit No..................... Dated......Street
.as shom�p-,q the application forbis'p� o*sal Works Con I u ory ............ . .
e.
.............................................. ------...........
Board, alth
DATE_..... ....P14C........'741......... ....
FORM 1255 HOBBS PUBLEPHERS