HomeMy WebLinkAbout0056 COUNTY SEAT STREET - Health (2) sly cc�M-q�-
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
tt
Applirtttiou -fur Mspoiitt1 Workii Tonfitrurtiou Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at,
a
Lo io ._Address or Lot No.
- -----•--•------ -•-----------------••-•---•------••---------Add----____--------------------------------
,Ht ress
n taller Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms-------................................Expansion Attic ( ) Garbage Grinder ( )
Pk Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' Other 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....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet-------------------- 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..------_------.--.--.-.
Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water-_.-_._...--.---___-.---
W --------------------------------------------•-•------••-•--------•---------------------•---------------------••-----•-•--------•--------------------_-----...
Descriptionof Soil---------------------=- = _------------------••--•-------------------------------------------------------------- ------------------------------------........
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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 b,e�"�ssuedd y the b rd of hea jY
T ae„ t
Signed1-11, : { kip ............... •--------
D,ate
: .
Application Approved By.... .4 . . -- G `d° `�'�" --- :fat- ea...... .......#'- fate
Application Disapproved for the following reasons:__---------------------------------- a-
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-••-------•-------------------------------------------- -----------------------•-•---•--•---------•------------••--•••--------------------------------------------------- - -------------------- ----
r _7 Date
PermitNo...........-............................................. Issued----- -- ..............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 1OF HEALTH
1 a
. .................
4 (Iertifirttte of f911lip aurr
THIS IS,TO CER aFY, "t the Indi} dual Sewa Disposal System constructed ( or Repaired ( )
by........:
Instate
'� -:_
has been installed in,accordance with t provisions of :Article I The State Sanitary C�eas es rib e
f application for Disposal Works Construction Permit No---
------ ___ ________. dated..._.F _.._..__
THE ISSUANCE OF THIS CERTIFICATE SHALE, NOT BE CONSTRUED AS A GUARANTEE THAT THE'
SYSTEM WILL FUNCTI N SATISFACTORY. IV
%
DATE.---- -��A--• ----2""'................................. Inspector------ •---
M�4� . r c
THE COMMONWEALTH OF MASSACHUSETTS
BOARD p{TO HEALTH/
yJ f� ��7{�+�'
d �` M Fr a O F.... ..................
.... FEE No.. __r
....
1� �i��u,�tti urk,� ,uuurttu�t err
Permission is hereby grante •• 1r ......................................................
to Construct ( ) or air ( Individu i��SewgDispgs 1 stem -=
s ,
at No.. n --
Street '
as shown on the application for Dispos Works Construction Per �_ a le .... ---- ; .�.. ._.__.__
e .
` f� `Board of Health
DATE-----------------------------------------------------------------------=---•----
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS