HomeMy WebLinkAbout0020 ALICIA ROAD - Health (2) 20 �3-c�, u.c�. ��
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THE COMMONWEALTH OF MASSACHUSETTS
BARD PF HEALTH
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ppliration for Big�rosal orkii Tonstru.rtion rrutit
Application is hereby made for a Permit to Construct (-k) or Repair ( ) an Individual Sewage Disposal
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e----- Latio A rs or of
..--- - - - - ---------- . ---------
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wner Address
a . .s _ _ ...-•----•--_.._ . . . -------•-• -•..............•----• ...
Installer Address
d Type of Buildir Size Lot__�.2_'t -----------Sq. feet
U Dwelling No. of Bedrooms.............................. .. Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons____________________________ Showers — Cafeteria
P-1 Other fixtures ......................................................
W Design Flow ____________________ gallons per person per day. Total daily flow_.....__._..... _��--__.__ allons.g< P P P Y Y g
WSeptic Tank Liquid capacityl gallons Length................ Width---------------- Diameter................ Depth__---___--__..-.
x Disposal Trench— o..................... Width.___.....___ Total leaching area....................sq. ft.
Seepage Pit No.... ............ Diameterl __ ep e oenin et_...._.........�.. Total leaching area__ ? 'sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water-_-___-___________--_...
LTA Test Pit No. 2................minutes per inch Depth of Test Pit---------- ______ Depth to ground water._-__-_____-________---.
O
Description of Soil..................... _
x
U -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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 fiI of the State Sanitary Code— The under ' ned further agrees not to place the system in
operation until a Certificate of Compliance has b iss d by th d of health.
Signe . -- •------------•-•------------- -----------------
Date
Application Approved B ._ .-__ __
PP PP Y --- - ------ y'
Date
Application Disapproved for the following reasons--------------------------------------------------------------------------------------------•------•-----••-----
-------------------••----------•------•------•-•-----------•----•------•-------------...•----------------------------•-•--•-•-•-•---••------•---------••- ---------------------------------------------
Da e
PermitNo......................................................... Issued.-- .........
Date
1
NO...... r................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® QF HEALTH
..................OF...... .
Application for 43iiiVasal Workii Tonotrurtion ramit
Application is hereby made for a Permit to Construct (to or Repair ( ) an Individual Sewage Disposal
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pIcatioAdress or I gt b
r wner Address
-----� '-A- ......... •. ................. -•---•-•-•--------•--•...................•----•-•----• ----------
nstal er Address 4��,Q,,-1
d Type of Build iSize Lot...._. _ q. feet
O DwellingNo. of Biedrooms...___.....___________________________Expansion Attic ( ) Garbage Grinder ( )
H
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures -----------------------------
W Design Flow........................... "d..........gallons per person per day. Total daily flow:--------------- -elt`d---_-----gallons.
WSeptic Tank-Liquid capacity/.rlP`-kallons Length................ Width----_----.-._-. Diameter_-----.----.__- Depth-.-.-----.------
Disposal Trench—No_____________________ Width-------------_ L;en;�.o_______.____ Total leaching area__.._....._......_.sq. ft.
Seepage Pit No.___ _ Diameter ___ _ e °"._._ Total leaching area__-_(�. :.s ft.
------ // ./ g q
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--.-_--.---.--._-----..-
GXq Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-_--.-____--_--_-----._.
a' •-------------• --- ----•-......---..........................................................
O Description of Soil_________________________
x
r, ----------------------------------------------- ----------------------------------------------------------------------------------------------------------
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 under • ned further agrees not to place the system in
operation until a Certificate of CompliAhnas14d by thb a d of health.
. -• •. -••-•-•-------••-••--•-•--•.. ................. •----
DateApplication Approved By__-___ _..
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Date
Application Disapproved for the.following reasons---------------=------------•--------------------•------•----------------------------------- -••------------:--.
-••------------------------------------------------------------------------••-----------------=---------.------------------------......----------------------------------------------------------_---•--
Date
,.. � �. ---- 'm
Permit No.----•-•--------•----•---•---••--•••--•-•-•--••__---- - Issued......
-- ---•----
� Date
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THE COMMONWEALTH OF MASSACHUSETTS,
BOARD OF HEALTH .
............OF.... ...�., . "....., ... ..............
Trrfif uatr of (In�1ilianre
TV HI TO ERTIF That4tlindividual Sewage Disposal System constructed or Repaired ( )
by..;",. - --- _ .......... ------ .................................................a I +In,,alIert --4at --has been -installed in accordance with the provisionrticle.XI o The State Sanitary Code as described in the
application for Disposal Works Construction Permit No__________________________ __ dated.--__-----_---_--.__-__-_-__-_:_________________
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT EE.CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
.3 _ _ 7
DATE_--------=-•-------------------r--7--.._..__..�._..---------•---....._.__ Inspector----------���E--- s� �.----- -------------------..._.._..__...--
.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
... .. ...OF.........� � `"m" ea ... `'
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No. •.-• -----•_-- FEE
IT
Permission is hereby granted_ - -------------- ------•---------
to Cotistr t1 or R air r
( ) p (• an Lndivldu l Sewage ' tsposal Syst ,.
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at No. �•---- .fsu_-�_ - - � �c -"----- ----------------
--------------------
• Street
as shown on the application forrDisposal Works Construction rmit No _E _____ Dated__. .« _ _ _:________
_4" --- -------
�- Boar 'of FIea1N
DATE........... .� r
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
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