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HomeMy WebLinkAbout0095 COMMERCE ROAD - Health �S �Yn YYI -JCf� S e S . i d No....:.................... Fxx.AL-1................ THECOMMONWEALTH OF MASSACHUSETTS B®AR® F HEA T � L ... :.-..OF....... .... .--- --- -------- AlIVIkation for l iipiial Works Tianstrnrfiun Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: ..........O-1?.Y1.Xn_&X'_4tA: ...._..R 52 2t_1.-_._ __a nnaf 4le.---------------------------------------•--------------------------------------••----------M. . Lqcation-Address or No. i Owner A ess ................................c� - U..�. .r.�. _____�: �_ _ __ _ ___ e. o__ � ... .�.ad.•_--•----yY------- - ............... Installer Address' , QType of Building Size Lot............................Sq. feet U Dwelling—No. of. Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) pa,, Other—Type of Building ---------------------------- No. of persons.......................,.... Showers ( ) — Cafeteria ( ) ` Pa Other fixtures ----------------------------------------------------- i 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...................... ."'idth.................... 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-...._--_--__-_-__------ 0 Description of Soil------------------------ =x U ------------------------------------- ---------=------------------•--------------------------------- ------------- } - ----------- U Natu j of Repairs or Alterations—Answer when applicable...f_.4g.D�___-SOL_ _�. ___ _ ,-k_�{___---__ Agreement ` The undersigned agrees to install the ,aforedescribed Individual Sewage`Disposal System in accordance with Y 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 {> Signed------------------------------------------------•--•-•------ _----- F -------- -------------------------------- Date . Application Approved BY..............y...........-•--•• -............................................................ ----- Date _. Application Disapproved for the following reasons.:................................................: •-----------------•----.— Date Permit No:..... ....._.3.a_--. Issued.... - l, -/�-_d"---__-- - Date Fns.....9! ..............._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............. .. ......................OF....................----..............--------..........................-------------_... Appliration for Disposal Marks Tnntrnrtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair (✓S an Individual Sewage Disposal System at: 1r�7 ,(�Oatnm•�rG --1 1pn�C1 +✓a Y15 ...�I•.�............... r a Locat on-Address (/� w, p or Lot o. :. ...................................... Y..®_::.A. .:..rX...li.J...t........ .:........................-_. .. ...... .......... .......... ' W (2nj t Owner II.. ddress 2usa. .....-- V.f:.k.l!�. �.! .�.---•--•••--.......... 1N� .........._JC a InstalleY Address dType of Building Size Lot...........................Sq. feet V Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( ) Other—T e 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. 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........................ R'+ ........................................•.................................................................................................................... ODescription of Soil........................................................................................................................................................................ x fs1j -------------- -- --------•- .-._...._... U Nature of Repairs or Alterations—Answer when applicable.._1__®.© _. _t:..... . ��'l ___.."-- .►'1. ........k!)..... .. r _e� .�- I e c}Z ► -----------3 on P e�_K>�c --------------------------------------------- .......kAgreement: 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. Signed..............• --- Date ApplicationApproved By.................................................................................................. -------••••--•--•---DaYe.............. Application Disapproved for the following reasons---------------------------•-----•--•-•-•-------------......-----•--••-------•---------•••--------••-•......---- }: -•-•-------------------------------------•---------------------•-----•--......------------------------------------------------•------------•-------------•----•-------------------------------•--•-..._ Date Permit No.....�?!T YYJ 0 V .---....... Issued.._. 3_...._. Date --•--•--•-2-------• � .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . .........O F........��.. _................................................ TvIrtifiratt of Tomplianp TV IS TO ERTIFY That the dividual Sewage Disposal System constructed ( ) or Repaired by..... ... •--...... -_... . . .................................•........... ........................................................_ Installer at...NX ��=2 .------- _._. '.��............. has been installed in accordance with the provisions of Article�of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUOICTIOP SATISFACTORY. ...................... Inspector........1.4.1. ..Zll...1.. ... THE ......._....._ COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........I...............I...........OF..................................................................................... No......................... FEE........................ Disposal 19orks Tonstrnrt#iun rrrntd Permissionis hereby granted.............................................................................................................................................. to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo...................................................................................................................-........................................................................... Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... ...........................•--.........--------•--................---•-•-••---•-•-...................... Board of Health DATE...............•------••--•---•••-•--........•---•..........---............... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS