HomeMy WebLinkAbout0033 ALICIA ROAD - Health (2) A-U
33
No—Irl............ o .........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.... ............. ......:..............0 F....... ........... .. . . .. . ..................................
Appliration for Disposal Works Tomitrurtion Vanvil
4;�Application is hereby made for a Permit to Construct ('--') or Repair an Individual Sewage Disposal
Syst t:
............. .. ......
.... .. ------ -- -- ---- ---------------------------......
L cation•Address or Lot No.
Owner Address
............... ................................... .................................................................................................
Installer Address
�
Type of Buildi n jo� Size Lot............................Sq. feet
U
Dwelling—No. of Bedrooms________0..................................Expansion Attic Garbage Grinder
a
Other—Type of Building --------_------------------ No. of persons____________________..__.__. Showers — Cafeteria
Otherfixtures ----------------------------------------------------------------- -----------------------------------
------------
Design Flow................... ...... a ons r person per day. Total daily flow__._.__.____.._. ------- _____-___gallons.
Length----------------
9 Septic Tank/-Liquid capacii a VnLength................ Width---------------- Diameter--------------_- Depth---------------
04,
Disposal Trench No_.................... Width____ Potal 'th. ... .......... Total leaching area_.__.__ -------sq. f t.
O'�, in,
_____A,pth— -- --------
--------------- Diameter/. _�. d.>-5Vr. ft.
Seepage Pit No.. ilef............... .� Total leaching area.
Z Other Distribution box Dosing tank ( )
14 Percolation Test Results Performed by......................................................................... Date----------------------------------------
Test Pit No. I................minutes per inch Depth of Test Pit__________._._._____ Depth to ground water.______--___________--._
f1, Test Pit No. 2................minu s per inc Depth of Test Pit___.._.___ ------ Depth to ground water_________________._._.__
it
............ ---------------- ... ... .... .................... . ............................................................................
0 Description of Soil----------- .. ...
....... ... ........I.......... --------------------------------------------------------------------------------
...........................................................................................................-------------------------------------------------------------------------------------------
---------------------------------------------- .........................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable-------------------I----------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------
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 Ugt to place the system in
operation until a Certificate of Compliance has be issue y the bo d ealth.
ggned.. . . ....................................----------------------- --------- -------------
--- -------
'�.-��D -------------
Application Approved By............. .. .... ....................
Application Disapproved for the following reasons:------------------------- ---------------------......................................
................................. -----------------------------------------------------------------------------------------------------------------------------------------------------------------------
Date
Permit N Issued_ .............
` Date
—---------------------0,---------------***--,-,-,"-"-,-"","-,---,-","","",- --------------- ---- --- - ---- ---
.Gy .....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
- ---------------OF........
fs Ems% fi� <
Apphr atian for 43Wposa1 Worko Tonotrnrtinaa thrutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System,at
,.
Location-Address ✓ r for I oY�No.
_... .. a .j • ` ............................... ......
y
Owner Address
W ......--••-----••-----••-----•------------------
gaffer
` Address
Type of Butldin -h Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms_____________ __..________.__Expansion Attic ( ) Garbage Grinder ( )
44 Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
A'I Other fixtures
W Design Flow________________ �_ galloon person per day. Total daily-flow_...____._.___ .+ .___gallons.
WSeptic Tank�Liquid capacrt ' on Length________________ Width.........._..--- Diameter_____ _._ .___._ Depth--__ ___-_ -.
x Disposal Trench—No_____________________ Nti idth__________.__"`:". Total nth._.__ -_____Total leaching are--t______________._____sq. ft.
Seepage Pit No_ ________________ Diameters ___'D �1 t e .._____ __ Total leaching area_.•.
b ,� : 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___._.________________..
(C, Test Pit No. 2..._____________minut s per inch Depth of Test Pit___________ ... Depth to ground water------------------------
P i . ------------/....
...........................................
Description of Soil------------- --- --
: s � _---- -------_- _ '$ � - -
x , r V.f
U --------------------------------------------..............••-•••=----=•-------•-------•••• •-•--•-•----......--•--•-=••-•--••--•-•••--•-•.....................................................
VW -----•••-•---------------•••--------------•••-••-•------•-----••-•••---••---•-•--•----------•---------------------•----------=--------------------------------------------------------------------------
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 undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b n tssue5�;by the boyad ofaliealth.
5 #
Application Approved B '__ Dat
f Date
Application Disapproved for the following reasons------------------------ --------- •-------------------._...----------------------------------•-•---
-•-•----•-•-----------•--•-------••-•-•-•••--•--••---------•--•-•••---=-•--------•-•-•---:...•--••------•-----•-•--••--•------•=---•-•------••---•-••--•-----------•••-•-•••--------•-----•------......
Date
PermitNo......................................................... Issued.---
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD. F HEALTH.
.
. ..........OF.... .r 67 at .. .........
�p�ifirtttr iaf ���t����tnre
T I TO RTIFThat the Individual Sewage Disposal System constructed ( or Repaired ( )
bya _ r .� ----- ------ •----------------------------------------------------------•------------
* Installer
g 0�
has been installed-in* accordance with the provisions of Article MY of The State Sanitary Code a des ribed in the
application for Disposal Works Construction Permit No________________ " 1 ` `----------
��--- ---------------- dated--- - --,����---- -�••�.._
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GU RANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
r
DATE. fit s :.................................. Inspector---. •� "l , -
�^ THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA1 TH
C11--7
........ af. d't .....OF..... er.
N
y FEi--- _
Permission is ereby granted_____
V.444 --- -
` 4 _____________ __ _ _____
to Constr '( or Repair ( ) an In td4ial•Sewage D s os'1 Sys
at No. = m �`
--
' x -;. - ---------------
'�
as shown on' the application for Disposal Works Construction P,-r t NO.- _ ;_ Dated._:" ___ ,_______________
�/
r.. � �� ! ,. .Board of Health..
DATE............
` ..............................................`.,.._ j
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS - R • • -
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