HomeMy WebLinkAbout0028 TEVYAW ROAD - Health (2) 26 T Fv YA W R D z.6q z�
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THE COMMONWEALTH-OF MASSACHUSETTS
BOARD OF HEALTH
...........)_.Owoo...........0 F....,e a rb-47, -----------------------------------
Application is hereby made for a Permit to Construct or Repair (L__� an Individual Sewage Disposal
System at:
Taqaw..Road...................... ..................................................................................................
Installer Address
Z Other Distribution box ( ) Dosing tank ( )
------'''-'' '----'-'------'----------'----------------'—
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� The undersigned agrees to install the ufo,odexcribcd Individual Sewage Disposal System inaccordance with
the provisions of�Z�lE 5 of the State Sanitary Code— The undersigned further a��so� to place the system in
operation ou6\ u Ccr�6�ue of Coonz� �co 6uy i 66 board ofhealth.
Compliancel~~
S�o�d--�Fs�,_� -'��-�� ��^�--- -����������---^� ` om"
Application Approved 8v- �rr--�---_----"--------------_-_----'------- --------.---_--_____
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Application Disapproved for the following reasons:................................................................................................................
_--_--'--___.-__'--_—_'-___'_--__.---__-._-----.---'---------_----'--------_-----_----------
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' Permit
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ;OF` HEALTH
VF
........... 6` ...........OF....a :. . ................................
Appliration for Disposal Works Tnnstrurtinn ramit
Application.is hereby made for a Permit to Construct ( ) or Repair ( r•:) an Individual Sewage Disposal
System at _ 1
........... y {{ Y c *� �!...................... ......••---- _:--- ... -• •--.......-----...._._...........-•-•----
ti L�ocatusn Address or Lot No..
a 'art.E7dr ;_ ' d r/ 1��l s� RSA °> �'�i
..... f - f s s.- •. ............. t} .,.� - ....................................
1 y Jy y `Owner /_ t Address
W ................L..t'. 1..���I ._t� 1 sal ..3e!:�:.® L ./.1.4. 'ir _" 1................ ..........._
Y-1 Installer 1 Address
QType of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
a
a, Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
QI Other fixtures ------------------------•--------- ------
-------------•--------
W Design Flow............................................gallons per person per day. Total daily flow.............................................gallons.
9 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
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------ ...........
Test 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' ---- ---------------
......
................
.....-------------------------------------
.......... ------
..._...___•--
O Description of Soil.................
x
W -------------------- ---------------'---'---------•••------"-•------••----••-••-•-•--•--•--••----'-----'----------------'--•-•----•••-----------'------•--'------•-•----------------------•-----•-
UNature of Repairs or Alterations—Answer when applicable........... .'..%_/='_. ____t '4` ��r ✓ '
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of:TTi,;a. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health
Signed `} `` ?� °°���..� . -_._ s��"Z,:f
..._
_
Date
ApplicationApproved By------- ---•-•-----------------------------------------------------------------------------
Date
Application Disapproved for the following reasons:................................................................................................................
-------------•---••........--•-••-•------------------•••-----------•••-••---------•-----------------.......__...--...'---------------••--•-•-----"-•-•---••-------•------••---•-•••---•'-----••--------
Date
PermitNo.-----. ----•-•----------.. Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............. .... ':,, ..OF.... � - "`y._' F.r ... ��.' .: ...............................
y..
rrfifirate of Bunt liana
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by---------__.�)-.' r s i�1e r'e ;`'��`' __` x�"� "`r
......................................•-----_----
at hy
'I p tr±` t � I F taller p Cv }��IJzf9
has been installed irt/accordance with the provisions of TI T L`, 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated................................................
THE ISSUANCE OF THIS CERTIFICATE ;SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..................=............ _�1.,.................................... Inspector...........7 ,1Zlel-----------------•----------•-------••-•--•--••--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No......... FEE ...-•...'=....--....
nrk$ Tg;wtr Ilanfgrmit
Permission is hereby granted........... I f % . f..... _� rr�'�'...............................................
to Construct (---)..or Repair ( .j,,, an Individual Sewage )Disposal System
at No. ;r-
Street
______________ _______ ________� C.�, �
i
as shown on the application for Disposal Works Construction Permit No.__.___ Dated_.______.... f_/ ..z?_.!............
DATE-- p ,� VV----------------------------------••---
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS