HomeMy WebLinkAbout0032 GLEN ROAD - Health (2) 3a Co h°,n PtOA
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® F
H EAL
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Applirativit for Ugipaaiial Hlorks t�#�ILiaC�taaYt P�'YYit�
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
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� Lot1N.............. ..... Jl.,.h .. .t.l�. .... .a.. l�i{JW
� w .• Address /
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a .,>.. 1. .... .. r........ ..........................>............................ ...................................
staller Address
U Type of Buildi�pg Size Lot..�s'�a ;Y. ..Sq. feet
Dwelling L No. of Bedrooms...........................................Expansion Attic ( ) Gnbage Grinder ( )
a Other—Type of Building .......... .. No. of persons............................ Showers ( ) — Cafeteria----------------------
( )
< Other fixtures .
W Design Flow:...:.................. ... allons per person per day. Total daily flow.............................................gallons.
WSeptic Tank—Liquid capacit}r -.-.--.-.gallons Length................ Width................ Diameter................ Depth..............
x Disposal Trench—No..................... Width ....... Total Length.................... Total leaching area.................... ft.
Seepage Pit Np.....I-------------- Diameter...f Depth below inlet.................... Total leaching area3...d...-_--_..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-__..---_-_-___-______--
LX4 Test Pit No. 2.... .........minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 .........................
.....
............. ................. ---•••----....- -------------
O Description of Soil
V .��� — ) a..... . s ' —Q �i,�a; s pro. !�_--
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-----------------------"`----------------------------------------------�--------------------------------- ------/-- -------- --------------------- -•-• -A-�!......� A
U Nature of Repair or ons—' —w�a. le- .__ __. ,er— �n
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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 been issued by the board
h.
Si ed. ,.�� .•--. Z* 4---••---------
A lication Approved B �f,� ?al�e�
Aplieatio Di ro d fyr the followin reasons:-_... ..................... .. la...--- — ..2-/I __
f
.. .. .j......... .... ......... • 41
........
Date
PermitNo........................................................ Issued.---�.. ....... -- ..................
ate
M1
...............77:
THE COMMONWEALTH OF MASSACHUSETTS
'BOARD H E A L-'F^
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Apphra:ti•oat ftr 13bripm al garkii % n0rurtion Vautit
Application is hereby made for a Permit to Construct ( �or Repair O an Individual Sewage Disposal
S stem4t:
...
• es �r s - ' of Lot N r4
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t n Add
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.,.... 5�..y1 .. s .f . .`. f.. d....�.�...o� /. s
wt ex�� Address
.... ... ..... :Lr.L: ........ ....,........................................ ..............................................
a nstaller Address
Type of Building Size Lot _; w _ _.Sq. feet
.� Dwelling. . No. of Bedrooms............. .......................... Attic ( ) Ga•tbage Grinder ( )
aOther—Type of Building ----------ilROFNo. of persons............................. Showers ( ) - Cafeteria ( )
Other fixtures - ----------- --------•--•--...---- ----- .....:.------. .
Design Flow..................................." gallons per person per day., Total daily flow............. ............................gallons.
P4 Septic Tank'Liquid capacity/5-�gallons Length................ Widtli---------------- Diameter................ Depth................
xW Disposal Trench—No ................... Width ..... Total Length..................... Total leaching area ..._ _sq. ft.
Seepage Pit No... . Diameter_ ,' "� F q._____________ �._:4...x__ Depth below inlet:___:`...____._..._. Total leaching area , -- ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date.........................................
a 'Pest Pit No. 1................minutes per inch. Depth of Test Pit.................... Depth to ground water------------------------
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.___-___________•-__.__.
P4 .......... .........................................................................
O Description of Soil....................... ,. >• ----.
s
. .................................................................
U ........................................................:............... ...............................................................
W
V 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 been issued by the board of health.
Sig_ed_ k _:`�, 2 t •. �, � '- ...._...... ................................
*y
r �/ - .. .. Date
A lication A roved B /, -- - i ._. .__ _----- - � :, �
PP PP Y ate, , k _
ate
Application Disapproved for the f ing reason r"-- ----- _ ----- _ .....
-- ...__._. -�----- � ••.__
------ -- -------- - -- -- - --------
"'�".�� Date
Permit No.. Issued. ' lezl4..................
Zate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
t
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b I 0 CERT , T i In ividual Sewage Disposal System constructed'k a ')�or Repaired ( )
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at__ 31:¢+tt�3��; v= v ? . iora .!- e?r�it �, ---
has been installed in accordance with the prop tsio7s oArtic le 1I of Thctate Sanitary Cade as descrlb d m the
application for Disposal Works Construction Permit �o_______ _ _________ ____ ...____ dated.....__: yt ;_ '• �.......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT. BE CONSTRUED AS A GUARrANTE THAT THE
SYSTEML C � SATISFACTORY. fi
DATE--------- ........................•-......_.._....----••--•---_. Inspecto Z- 4 �....1/.. .....• • ........
THE COMMONWEALTH OF MASSACHUSETTS F
BOARD OF HEALTH
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Permission is hereby granted ................................................................„._
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to Construct ( 'f"or,Re�air ( ) a�n Individual SaNv�ige I,)i�s osgd�ystem
at.:No _ ... .< � . `• = _.:.. {�,-..��.M °, ..�{ ...._.... ...
Street `,.
as shown on the application for Disposal Works Construction nit No.. ated-,11 .0y..�'„�t...........
3
Board of"IIcalth
FORM 1255 HOSBS & WARREN, INC., PUBLISHERS '