HomeMy WebLinkAbout0081 STERLING ROAD - Health (2) <=� �?-��
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THE COMMONWEALTH OF MASSACHUSETTS /
BOARDQF HE
..............o .. .................................. . ............................------------.
' Appliratiun -for Ditivoti tl Workii Tonfitrurtton Vrrmit
Application is hereby made for a Permit to Construct (__<Repair ( ) an Individual Sewage Disposal
System at: /
�e .... .._- ----� -- - ---------
-----.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.--Address Lot No.
A�,
/ Address
a •------------ 's...L--..... •-----.- ..... ..................................................................................................
Installer Address
UType of Building Size LotJ3, _________________Sq. feet
Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures
W Design Flow.... ...................... Mons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capac?�' llons 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.......................................
a
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water...--------.-.-.--.-----
G%, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
•...................
...................................................................................................
0 Description of So*,----- --------------------- ........................
x
V ------••---•-•••-••---••••--------------------------•--•••-•----•--------------•-•------------------••-•-----•-••---•-•-•-•-------------•----•----•--.....-•-••-•-•••---••-••--•----•---------------
W ------------- -------------------------------- --------------------------------------------------------------••-----------------------------------------------------------------------------------------
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 be i ed by the and of alth.
DatesIrp
Signed
- •--'-Date---/--•---..._
Application Approved By---- --- •••-- ------ 1
Date
Application Disapproved for the following reasons:.................................................................................................................
.........................................................................................................................................................................................................
Date
Permit No..... Issued --------•- ----•-......-•••..............
Date
--------------------------------------------
..FED... �........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HE
4 . �r
COW
Apphrtt#ion -fear Bhipoml Workii Towi#rur#ion Vrrnti#
Application is hereby made for a Permit to Construct (-'or Repair ( ) an Individual Sewage Disposal
System at
;,
Fogat on Address a or Lot No.
------- ....•................. ....
Owne �y t +�.'T/� �p �q # --- Address
. `.e'aFi�......Y.. mn�f .. .............
Fri\ ............... ___._._..f.'.-..___ .._._.._ ..__..... __ .. __.._..._.......
__....._.._________..___..__._ ._.
Installer Address /
d Type of Building Size Lot_.1.....,r_'� � ...Sq. feet
U Dwelling—No. of Bedrooms..._......- ............................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons._-_-----.-•--_-__----_-_._- Showers ( ) Cafeteria ( )
a
d Othel;-fixtures -----------------------------------------------------------------------------------------------------------------------------------------------------
Design Flow.__,, <''_°`�- `' .............gallons per person per day. Total daily flow__..............._......._....._...........gallons.
WSeptic Tank—Liquid capac�itv-P�: 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------------ ---------------:---------
aa Test Pit No. 1----------------minutes per inch Depth ,of Test Pit.................... Depth to ground water___--_--_.--------------
G Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--._-.----_-------__-. -
Description of Soi...........:..."i..... .. ; �
x
W ----------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------
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
until a Certificate of Compliance has b ii§�bed by the board of 1 ealth. �f
operation een„� ( H_,r r r r i
,-ISigned ...t -------
' ..
,' c n . Date /may..
Application Approved BY '; t"�. • _ z 'L � :------ --------5� ,-/-�I
Date
Application Disapproved for the following reasons:----------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-17 Date
PermitNo.---_$................................................ Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD =F HEALTH`
... . . �
OF........................................'e.............................................
Trr#ifira#e of Ofknrutphaurr
THIS IS T,0'CERTIF ', That.the ndividu Sewage Disposal System constructed rl or Repaired ( )
by---------------- =` �'{-- r -
,. ,..y ,r •.r" r / Installer -
at...... -- ---��� ------ .-� --------------------------------•-----------•------------ ------
has been installed in accordance with the provisions of Ar ' I of The State Sanitary Code as de ribed in the
application for Disposal Works Construction Permit No._._ _________________ "
PP P dated : !. %' 1
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A�S..A GUAR NTEE THAT THE
SYSTEM W L UNCTIO -SATISFACTORY.
-•-----•---•......---•.. Inspector -0 ......-------
THE �
COMMONWEALTH OF MASSACHUSETTS. � f ,j�
fi •� BOARD )OF HEALT��a ��� � � �V
...........................OF °�_..e•y' .
No.. ••-••••--•- .. FEE.......................
Permission��hereby.granted-----�s-==-=Rol:c..��,,,�----�__t��t`,_•�=-`=�=�='='�-------------•----.............-..............................................
to Construct ( ) or j, epair ,{ ) an Individual Sewage .isposal System
at No. 'lid* r r 1 r .. ,. = •• -••-•--- ----
_ � -- r
Street
as shown on the application for Disposal Works Construction P t No.___.. ._.__ _ Date'-_ .:. f_. ___, :......
-- ` .: •�`
oard of Healt"
DATE--------------------------------------------------------------------------------
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS '