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HomeMy WebLinkAbout0060 PERSEVERANCE WAY - Health (2) Ve-f I • TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF FIRM: Pf0 r ---?f y- A, (- .2=,�c MAILING ADDRESS: TELEPHONE NUMBER: CONTACT PERSON: Does your firm store any of the toxic or. hazardous materials- listed below-; - either for sale or for your own use, in quantities totalling, at any time, more than 50 gallons liquid volume or 25 pounds dry weight? YES !/ NO This form must be returned to the Board of Health regardless of a YES or NO answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address : /NO ADDRESS: e" 0 /0✓?' h TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous characteristics and must be registered when stored in quantities totalling more than 50 gallons liquid volume or 25 pounds dry weight. Please put . a check beside each product that you store: Antifreeze (for gasline or coolant systems) Refrigerants Automatic transmission fluid Pesticides (insecticides, Engine and Radiator flushes herbicides,rodenticides) Hydraulic fluid (including brake fluid) Photochemicals Motor oils/waste oils Printing Ink i Gasoline, Jet fuel Wood preservatives Diesel fuel, Kerosene, #2 heating oil (creosote) Other petroleum products: grease, Swimming Pool chlorine lubricants Lye or caustic soda Degreasers for engines and metal Jewelry cleaners Degreasers for driveways & garages Leather dyes Battery acid (electrolyte) Fertilizers (if stored Rustproofers outdoors) Car wash detergents PCB' s Car waxes and polishes Other chlorinated hydro- Asphalt & roofing tar carbons, (inc.carbon Paints, varnishes, stains, dyes tetrachloride) Paint and lacquer thinners Any other products with Paint & Varnish removers, deglossers "Poison" labels (including Paint brush cleaners chloroform, formaldehyde, Floor & Furniture strippers hydrochloric acid, other Metal polishes acids) Laundry soil & stain removers Other products not listed (including bleach) which you feel may be Spot removers & cleaning fluids toxic or hazardous please (dry cleaners) list .: Other cleaning solvents 4 Q Bug and tar removers °° r Household cleansers, oven cleaners Drain cleaners Toilet cleaners Cesspool cleaners Disinfectants Road Salt (Halite) l No. `, .`_ .. �9 b ✓r�e�/ CSL W .FE$...: �� .............. THE COMMONWEALTH OF MASSA USETTS BOARD OF HEALTH , pphra#iun -for Diapviial Workii Tutuitrurtion Vrrmil Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: 4C �Z Location- ss��s 1 J or Lot No. = r ---------------- ----• f------ --------- -- ---- -- ----------------------------------- Owner tddr W � taller Address 6^� QType of Building Size Lot.9Qi:. Z'---I-------Sq. feet U Dwelling—No. of Bedrooms..____:______________ Expansion Attic ( ) Garbage Grinder (-=)------- Other—Type of Building •-!_-_ 1DgM!!4(;� No.- of personsYLAY.�_._'.__N ----- Showers (—) — Cafeteria ( ) a' Other fixtures ........................:---�---------- Design Flow............ T. .........................gallons per person per day. Total daily flow........(/-S ......._._._...._.....ga�lrgns. WSeptic lank—Liquid capacitvlV,0 gallons Length... 0.�-_ Width___......--- Diameter................ Depth....__._. x Disposal Trench—No________________•.__- Width-.--__..-_--______-- Total Length-----------_........ Total leaching area.....---------------sq. ft. Seepage Pit No..l_-_�_------ Diameter...j_' /------ Depth below inlet....r�............ Total leaching area-1...._----Sq. tt. Z Other Distribution box ( ) Dosing to k ( ) Percolation Test Results Performed b .............!?-�l_ _..� �__5......... Date.a.��__ _`___ ��__.__.. a — Test Pit No. -__-_minutes per inch Depth of Test Pit.../. __.... Depth to ground..water..- - fs., Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground wa - - -QF-Mq�s - _ . ---•-•-- ••• . -••-•---•-----•-••--•-..._•--•................•••-•••.... Descriptionof Soil----------------�% .... J� ----------------------------------------------- �. �a------•---------•x` v •-•--••--•----•-•-----...••-------------Q-1 ---------- ------•--�C.Dol m........ So i. ._.C�. o- -No..--------- W, z 40-- U Nature of Repairs or Alterations—Answer when applica.ble..-------------------------------------------------------------- - --P ...._-_---__-.---. --- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal Syste i accordance with �(( l the provisions of Article \I of the State Sanitary Code— The undersigned further agrees not to place the system in q.. operation until a Certificate of Compliance has been is ed by t e boa .ef h. e Sign •---••--••--. -••... ...-•. -••-----. ............................ Date Application Approved B 3 PP PP y---- ---- - s' L: aD r- . Application Disapproved for the following reasons:...........................7 --•-. -•... ••....•-•••-•---•-•--•--•....---••-••-----•-•-•......•••-- ••--------------------------•---•-------•-------------------•-•----•---••••----•....----•••-•----•••-•--.._---•_.....----------•-•-•-•-.... ------------------------------------------------------- Date Permit No......................................................... Issued; --••-- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 0 A e N S T'�4�3 C..E .----------- ---------- Applira#iutt -for i.s uiitti Workii Tutuitrurtion 13rrmi# Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal System at: -------- WAY------ ---------=-------- T---------- 2= . ---------------------------------=--------------------= Location= ss or Lot No. �+Y Owner> ddr a: -----. . ............. taller Address rr�� ,`Q� Type of Building Size Lot_ Pj.L z.._1_-__--_.Sq. feet �^ Dwelling—No. of Bedrooms......_- ---------------------__Expansion Attic ( ) Garbage Grinder Other—Type of Building _ _ US_�: 1 �- No: of persons: : _.___ ©__.__ Showers (- ) — Cafeteria ( ) G Other fixtures ----- --------------_-- ----- ------------------------- W Design Flow------------1_-�_'.:........................gallons per person per day. Total daily flow-------- �____________-...._.--gallons. WSeptic Tank—Liquid capacitv/20Ugallons Length___ 0_�_.. Width_.__G_.�__.- lliameter__._....__.____ Depth--- �tili�/. x Disposal Trench—No. .................... Width.-_---____--___-._-- Total Length__- i ....._-- Total leaching area--------------------sq. tt. Seepage Pit No.. _-..2...._.. Diameter Depth below inlet....b_..__.____.. Total leaching area _8.8_._sq. ft. ._ P. Z Other Distribution box ( ) Dosing to.4}'!�k ~" Percolation Test Results. Performed by. vh-h----- Cc?!?.E�....... ........ Date.a. S a Test Pit No. _____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__-_ . p -�"------.2- ,,, ------- Description of Soil---- ." 4 =''= L LIC1 c7 ©�eE� P - ••--- dp------------------ ----------------------------- -- x //_ ��� _ _ � -- - - w --------------- ¢------------¢4-....------���!_v��j-------�'`'N�-, --�-of''-�.... .- -� � -----------------� ------------------------------------------ ------------------------------------------------------------------------------------- --------------------------------- ....... ------ U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------ . ....__._.40- ---------- - --------------------------------------------------------------------------------------------------------------------------------------------------------------------- - ---------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in rFl�c�`.R'rlNi} the provisions of Article \I of the State Sanitary Code—The undersigned further agrees not to. c the"j operation until a Certificate of Compliance has bee i ed by _ e bo h. Signd -•-•- --•--- ----- ---- ----R- - ------- -------------------------------- Date Application Approved B .................. ' ` /-r-_r- ------ Date Application Disapproved for the following reasons:------••----............- •--•-----•-•-------••--------•--.....-•---------•---•----...--•-----•••-•••- ..........-••---•--•-----•-•--•••-••-•••--••••-----•••---••---------•--••-•--••--•-----••---••-----•--•-------------•-•-------------••--••-------•-•----•••-•--•----------•------•---••.....------------ Date _ PermitNo---------------------­................................. Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS �., - -BOARD OF HEALTH ..................N oF........ 4Rw.S. A. /�T...........................:... xr#ifirtttr of Trrntphatta THH�G RTIFY T the Individu Sew Disp System constructed (X ) or Repaired ( ) „- bY '!`"cam •"" ' l --._. l� �f - to er at �bT.... . -_2. . �,� SF. -------E �1 �✓ 4-�------ 'fl y i�tl�rv� �` .. . ------ ---- las been installed in accordant'with the provisions of A 1cl�I of The State Sanitarvdg�de as described m the pplication for Disposal Works Construction Permit No. __�"s__ _.?_,4................ dated_.. '�",,,�_`"`"� THE ISSUANCE OF THIS (CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................. Inspector.................................................................................... THCOMMONWEALTH OF MASSACHUSETTS f BOARD OF HEALTH 1_ �..o........... oF........... . JS....-� . ...�.................... ... �i� tttt orkii Qlvttrttriottrrmit d t ig . � Permission is hereby granted `------""-- -----N ----------- ----- ........................................ to Construct„ ) or Re it ( ) an Individu4 Sewage Disposal System l '' at No...'•------•-•--•-•. Ems? e� _ .!4 n ...... 69 f 'l✓i� Street as shown on the application for Disposal Works Construction Per No. .;...._._... Dated ,t ]�"`"' •- f . 2�- 77 oar ealH th t DATE.--Z. .----•-r_ -----------•G-- ....----•---•--•---- FORM I HOBBS & WARREN, INC., PUBLISHERS 5 " V\ CIJLDE54C \)r�IZAD' ,� .1 SEPTIC -j INK AND SEE L E 0-1 FIELD Tl� I A -A P5 col / F A,r LJ f 5 \ GJ ` / \ t �07 (r We \ J 0 CaDJr'�� y ,f' 2 1 . • �� F��. �� r �ors.� .SE�� /.��� ,� ------ -. •C i i s h' Cw. c J< 'E' G'7;�v .7"/, L 1r . v l-� J "� _ �L T Y ..�.,� Z� �- / � ,r � BL mac. �� 9 ��.1 ��. 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FT. _ L 07 . : ; M/`OQKEN BRCTHER5 P� P ° C.- AN �FMgss9c 15AQN5T/�&IrIE M/�SS. o �os n bRTi f NDUST(Z!/�.L C,C)MMI-RCl/�,L ENC�INEER5 INC. 401 "' No y IW E M C)U H M�,5 S. EDo`��. wC�. C'(' L� PPfZovED 5C4�E: A NQ v tC H K . 5Y: La T I— ITITLE s DWC-1. NO._ _. 5 ITC PL_/N 5 P- 1