HomeMy WebLinkAbout0052 FIELD ROAD - Health el c 1Rc a4
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LOCATION SEWAGE PERI3IT NO.
VILLAGE
lyJaflt �n tin f�� '
tqS LL 'S NAME i ADDR_ESS
GUILDER OR OWNER.
DATE PERMIT ISSUED „ -,;2L
DATE COWPLIANCE IS-SUED /n /�
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THE COMMONWEALTH OF MASSACHUSETTS
BOA OF HEA TH
v. .. .............oF.... ..... , 5 6---..............................................
Allp iration for Diapuual Works Tuuitrurtiurt Vernfit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
L ocation- ress •.••••••••-.-.or Lot No.
... ..........���n- ® ......... ----_--------._...- ----------------------- -------••---•--•-------..-.-.-----------------------
Owner ddres
a -J set 1- ------------------------------------------------------- �� T s...-
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms..........:3.:........................Expansion Attic ( ) Garbage Grinder ( )
a4 Other—T e of Building ..............
Other—Type g �iQ��.(�(1�/_1t�.4No. of persons...._... Showers ( �) Cafeteria ( )
dOther fixtures -----•-----------•---------------------------------------•••......-•--•---•-•=••-••••-- ••---•••---------•-•--••-•••--.......--•••-•-•---....__-----•
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity........--..gallons Length................ Width................ Diameter-------.-------. Depth.............
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.....................
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 ••---••••-••---------------•------------•-........••-------•••-•----•-••----•••-..................••........................................................
0 Description of Soil........................................................................................................................................................................
x
U
x - --- - •..
U Nature of Repairs or Alterations—Answer when applicable--------------S,2V_A:,e.......... .--..-� .........
Agreement:
The undersigned agrees to install the.aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITi U 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has een i ued by the board of ieajkib
e
Signed -• ........ ......................................... ....
w�6A
Date d
Application Approved BY ----------------•••-
Date
Application Disapproved for the following reasons:................................................................................................................
.....................•.....-------•-•--••------•--------------...-•---•--•-----------.......------------......•---...---•--------•-----------------------------------............... -•--•---------
Date
PermitNo.......................................................... Issued-.......................................................
Date
� c
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................OF�........ ns � .1 ....................................
Appliration for Disposal Works Tonstrnrtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
- -!. � .( (-l....ne ....M.J-•_____ ____________••----------•-••-----..__...___....
Location-Address or t No
-Lo .
Owner Address!f
,i�1 .� `� j .............................................
Installer Address
QType of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms______________ .._._Expansion Attic ( ) Garbage Grinder ( )
WOther—Type of BuilT51'109A-f�.&1?61.'1�_ No. of persons._.._____.............. Showers ( j) — Cafeteria ( )
dOther 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.............. ft.
Seepage Pit No--------------------- Diameter.........._......... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
14 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 --••---------•----------------------••--------•-•-•---•---•-------------•-•---•••-----...._.......--.........................................................
0 Description of Soil.........................................................................................................................................................................
x
V --------••--•••-•----------•••••---•------•-••-••------------------•--••-•---•••-•-•-•••_..•----------••••--•-------•-••---•-••-------•--------•••--•--••-------•--•----••--.._...........-------...__..
W --••------------------------------••--•-•--•--••••••------------...-••-----•-------------•-------••-----•--••••---------._....
VNature of Repairs or Alterations—Answer when applicable.....57d/t......____.. _____________________________________________________
-----------------------------------••-•••••-•-•-------------•-•-••-•-•---------•-•---------------------••---•-------------------•--•-------•-------•--••--•-••------------•••-•••-----------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLZ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has en(lrsued by the�boof health.
Signed- -• ...................................................... ........
Date
Application
srovy --------•---•---•-•-•-•. ................•-•-....--t•, •�.......
-•------••---•-•-••••--•--------_------
Date
fAPPlication Disapproved for the follo�wa9asonJ:__..
-------••-•--••-•------------••--•-•-----•-------------------------------------------------••--------------••••------------------------••------•-----•-•--••-----•---•••-•-----••-----•---•-•--........_
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r. /V...................O r. �`�� / .....................................
Trrtifiratr of Toutph atta
T IS CERTIF��hat the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by.......... _.r.= - ------------t.-'--._...---...--------------------------•---- -----------------------
at = 11�/- 1A.U.----------�ll n ller ----------------•---------_____---•-----•------___________--------------
has been installed in accordance with the provisions of TITIZ 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No----------------------------------------- dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHAIeI?NAOTte-tONSTRUEI) AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTIONSATISFACTORY.
DATE.......................................6 2.1 •f1-"-------.._..----- Inspector........... ............. ........................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�v....................OF..--.�.�e .
No......................... FEE.....
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tap arks � stratrtinn unit �
Permission is hereby granted = --.---------••-------
to Construct _or Re air Individual S K�age D's osal Syst
at No.-� ---.. J.t 1.. .----------- L.--�ll� _--
-- .._...
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
...............•---------------....•••--------_._._.._..._...--••-••-•---•-------•-------_----••-••-•---
/ f-/ IMHealth
DATE..............................................
FORM 1255 HOBBS & WARREN4 C., B.
E:RS