HomeMy WebLinkAbout0021 FRESH HOLES ROAD - Health (2) a� Fr esh 44olan
r
No. -.��/�`�
f THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
.....................OF..... --S A..!t-L 1:6...........................
Appliration for Uiipniia1 Works Tnntrnrtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair X an Individual Sewage Disposal
System at:
........ .----- t_1tY_dtW.4L5..................................... --•---------------............------------.. ..--------.......-•------...............--
ocat n Addres Lot No.
....... v_ C ... � ...•..----•-- .... .. l-�O
�.? ' .---.�.....
a .�r.►..._ r / C Address
..................... ...................--- ....... --.. . ..... = .............
Installer Address
Type of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons--.-.__--___-_____..___--__- Showers ( ) = Cafeteria ( )
Q' 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.
o
3 Seepage Pit N .-•______-_.---t.... Diameter.._... Depth below inlet.....�t...__.---- Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
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........................
----------------------------------••---------------------------•----........._.....................•........................................................
0 Description of Soil........................................................................................................................................................................
x
U --•••-•---•---••----•- ••-•--•---•--------••--------•-----•------•-•-•-----•-----•-----------------------------------•--•--•--------•---•••----•--•--••---•--•--•--•---•......-•--••--•-----------------
x -••--•-•--------------------•-------....•---•--•••-----------------••-••---•--•-•-••-•-•---.------------•. - - .. .......................
� P. F........ f
U Nature of Repairs or Alteratio Answer when applicable_ _ _______________' -�$?�ll. Cr- ._....
Agreement:
The undersigned agrees to install the afore cribed Individual S a e Disposal Sy min accordance with
the provisions of TI I'll 5 of the State Sanitary ode—The undersig urther agree not to place the system in
operation until a Certificate of Compliance has be ' sued by t boa of iea th. 1-3 , rz-11
Si --------- ---- ................................................. ................................
Date
Application Approved By............
= .............................................................. ••---••-----�
Date
Application Disapproved for thewi asons:..............................................................................................................
Date
PermitNo.---� __. ------------------------ Issued.......................................................
Date
No. Fss.....�....�...v.... ..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7 I"" .....OF..... ..`�...'..° .. 5"�"' .............................
Appliratiou for Mipoii al Worko Ton6tratrtivat Vantif
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at
...... ...............r:.....� eft.,�--------------------------•---....... .......---�f....---..�."......--------....-- ------------........_..•...----------•----
�"-i o f 1��.f�'�/�,cation-7A" res � e,I G- 7i f
ddre
� ,t
Dwelling' No. of Installer Address
� Type of Building Size Lot............................Sq. feet
g' Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
04 Other=Type of Building ............................ No. of persons............._-__--..__-___- Showers ( ) — Cafeteria ( )
QI 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...............I_... Diameter.......r Depth below inlet...... Total leaching area..................sq. ft.
Z. Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
GT, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ------------------------------------------•---•------------•---•-••-------------•--•------•...---•--.........................................................
ODescription of Soil.........................................................•-•--•-•'-•---------•-------...----------------------------•-----------------------------_•-•••...------_-_----
V ........_.. -•--_•....--••......••••---••-••••-•••.........-•-•------------•----•---••-••--••----------------------•.........._..---•---_------...--•--------•--••-•-----.------
W ...............................................-..........................................................
U Na ure epair r Alteration ns er when applicable .. __ _ .___.
-
...... ----- .._... ..:. ► .. w --------.---•---------------••••--•.•..-------•-...._..........••............._.--_.
Agreement:
The undersignedr,:agrees to install the afore e cribed Individual S a e Disposal System in accordance with
the provisions of iIT1.L 5 of the State Sanitary de—The undersig rther agrees of to place the system in
operation until a Certificate of Compliance has be n ued by th bo of h. rj ,
Si ....... ------•----'------------•---•-_--------••------- ---•-----•----•-----------------
-. -- --- - --
Application Approved By................ ............ ..--------------...... ........................................
• Date
Application Disapproved for the f ollowi r asons:-•-•--••-------••-••-••----•------------------•------------•--•••---------------------------------••-....------
...............•-•--•--.....-••••--••------•-••••---••••.....:--------•-------------•--------•-•-•-----...-••••••----•-•--••-••••--•-••••••-••......----------------------••--•----------------•---------
Date
Permit No. -....-- ----------------------- -: Issued.......................................................
................
Date
THE 4COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
:........:................................OF.....................................................................................
(Intifiratr of Tootph aatrr
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired
by ....... - ...............•--------------------•---------------•--- --
/- :, Installer d.,1 � '/fir�
at. ram_._..._.. =......•------------------------------------------------------------•------•------•-......-----------------
has been installed in accordance with the provisions of. TITLE j of The State Sanitary Code�s.dycribA ,in tfie-
, �, �j . . '�..�' B .
application for Disposal Works Construction Permit No.:_............. ........................ dated................................................
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE. / 1/_........................ Inspector. .. .......................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF `HEALTH
. 3�a..- ......................� .......OF.............:_:..1�.,€d��i}�b G�_-------•---..........................
No....................... FEE........................
Biupoutal rko �oatoriori anti '' ¢
Permissionis hereby granted------------------ --- -------•-•-•-----••--------•----•-------------------...-----------------•--.....:.-----p........................... r
to Construct ( -)'-or Repair ) an Individual Sew e isposal SystePI V/v,.,e/S
o �-
at No...... a " '� 1 ! G
_ •--- . .. -- ••••• •----w--�- ....................
r Street7 .q�
as shown on the application for Dispdsal-Works Construction�Permit No.....................f 11jated........
_... .........
IVA ..................' c:
DATE.... ' . V Board of He h w
•-----------••••------•-....•----- h •--
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS. 4t
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