HomeMy WebLinkAbout0063 ASHLEY DRIVE - Health (2) Drfve.,
7
No...J.. 3.......... F$$... ...... .............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
...........:.. oF..... � .
. .
Applira- v$t,for ispooal Works Tonotr ion........
Vrrutit
Application is hereby made for a Permit:to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
............ � :........................ :.....
J , ........... .............................................................
..........Akly ..C.L..Location
o�_ .......Xs .......1.� �.�. .... Lot No
...................
Owner Address
.........: .......... ...................... .. --•- ..__. .... ..............
Installer Address
UType of Building Size Lot._./4 l!M.........Sq. feet
�-, Dwelling—No. of Bedrooms......_.r... ..........Expansion Attic ( ) Garbage Grinder ( )
fld/�/ . ......._... No. of persons............................ Showers
p., Other—Type of Building ... ....____ p ( ) — Cafeteria ( )
P4 Other fixtures ------------------------------------------•-••--------
W Design Flow...................: .U.................gallons per person per day. Total daily flow.............. 4rD..................gallons.
WSeptic Tank—Liquid capacity/M...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..�6.1- ,sq. ft.
Z Other Distribution box ( ) tank ( )
aPercolation Test Results Performed by.:......................................................................... Date........-...............................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
�14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Descriptionof Soil------.... ----------•----------------------------------------------------------------- --------------------
x
cU --------------••--------•--•------------•-•---------.._...--------------•------------------------------------------------------------------------------••-------.....----------....._--•--_--•-•----•-•.
W
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 been is ed by iheo f health.
Signed... ?►- a.0:.... •........................... ............
Date Application Approved BY-------2efollowing
-==/�-/-=� .......... ----•---------------•---.......................... ........................................•---
Date
Application Disapproved for reason .---;--......---•-----------------------------------------------------•-•-------•-•--•--•_-:....•--_---•-.--•...
-•--•----------------------------•-••--------------------------•-----•-------•-------....------......-------•--•-•----••--•-•--•-------•--•••----------•-----•-------•--•--•_•............-•••_----•-•.
Date
PermitNo.-----<r.3....................................... Issued........................................................
Date
'
�m� -
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THE COMMONWEALTH pp w�ssuc�u��r�s |
\
������ ���� K-���
BOARD'' '-- -- ' HEALTH
^
.............. . ...................................................
'
for' �� �
��������x m�4�aK Works Toustrurtiou P-nuld
� Application ia hereby made fora Permit to Construct ( ) or Repair ( ) an Individual Sewage [)isooeu
System at:
Owner AAddress
12
Installer Address
Typ-0 ding
e of Bu7, Size .......Sq. feet
Other—
of
v
Other 6�tor�o
~� --------'.--___--___'------_-._-.---''__-'-_---___-'--_-'_
Design -gzD000 peryerauop�rdov In�a daily8ow. .................. .
^~~~ Distribution. . ~~ ` / ~.sing tank ( )
Percolation Test Ilcoubo
� �cc6000cdbv--. - ------- Iut�--_-.--.--------------------
Test _ , D
Pit No. l----_--minutes per�dh Depth of TestP�-------- ----.----
�Zq Test Pit No. 3................ per inch Depth of Test Pit.................... Depth to ground wztcc.-__.---_
c� �
D�ocr���n� o� -__'--_'-_---.--'__.-----_-'-__-'-
�
__--___..'.'-----_-'.'-__.---'-_------'--'_.-._--._'-_--'-_-'_--.'.--_----'--'- '--_-_-
'_-_----'-__.---__-__-_---.----.'-__-__'_-.----._-_.-.-__----_'_-_-_.-_'--_-_-.
() Nature of Repairs or Alterations--Answer when ---._----.--------'_----._._--'_--_-
----'-----'--'--------'------'---'''------------------'-----'-------'-'''----'-
Agrcrpzcor: �
The undersigned agrees to install the uforedescribed Individual Sewage Disposal System inaccordance 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 bee is ifed by t7hppbori'Mof health.
Date
Application Approved uy-.. ------------------------------------- --------------------------
Date
�I���u6uo ]��au�prov�6fnr rxoxo*xx��-_----------_---------_-.--------------------'
__'___-_--__---._. ................................................................................................................................................. ^ ` Date
Permit ___� __
n"*
'
^
' THE COMMONWEALTH orMAssAonussTrs
BOARD. OF HEALTH
� -----'��F� �'�-___'______-__
~ .
TH R That the Individual
or-
"k, Installer,
has been installed in uovmunce �� of
Article=~ / ff The State Sanitary Code as in the
applicationfor Disposal Works ConstructionPwroitJo---- - __---_- dated------°2--~_ ....)_3...................
THE ISSUANCE OF THUS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUN RY,
[b�T�.--.----==�~ - ��-��-��----�---_--'- '1'l- �� .........................................
�~ � --'--- \�- v~'`�--T�� �
�
THE cowMomvvsALr* OF MAsSAc*ussrrs
BOARD F H ALTH
.�
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]�m--��.�'_--- ^�- I��'-�....____-
~Boa rd "f ealth
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ronw /�ms *qBxs u w�nR5�.''vw�� pvousxcny ~�
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