HomeMy WebLinkAbout0020 AUDUBON CIRCLE - Health (2) ao 4udu bon u/ac� i t�n, -.
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No.__� _1 Fa$....... ./..��-
78 THEBOARD
COMMONWEALTH� FH�ACH"THTS
-OF..... ... ......................
qI I11� Appliration for Utspoiia1 Works Towstrurtton Vrruift
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System
---
Locatio -Ad Wires—� or �t lad
�`w /�
-•-- --- ----'-- -spa-•-------------------'--.._.-•----------------- ------------ - ------ �"�*---•::;�- ------•-------------•---•-----------•-
wner - -.•-.-Address
a •--- ---------------------•• •-'••---••-------- •••••-•-•-••-•••••............-•-••••--•-
Installer Address
Type of Building Size Lot_.l.--_ `Sq. feet
U Dwelling—No. of Bedrooms._........._
------------------------Expansion Attic ( ) Garbage Grinder ( )
PA Other—Type of Building ............................ No. of persons_---.----------------------------- Showers ( ) Cafeteria ( )
a Otlje fixtures -•--------- ------------------------------------------
W Design Flow...._.____._..................:...gallons per person per day. Total daily flow............................................gallons.
P4Septic Tank—Liquid capacit gallons Length---------------- Width_.__....._..... Diameter-------... ----- Depth----------------
W Disposal Trench—No. _.__._._ Width`=----- ------------ Total Length_..-.._-----_____--- Total leaching area------._-_-..___-_sq. ft.
p g �. p Total leaching area ___._. 1.See a e Pit No ___ ________ .Diameter________.____.______ Depth below let............. _--__-..-_sc ft.
z Other Distribution box ( ) Dosing tank ( ) D4— �/ /'�&/ �����
W
Percolation Test Results Performed by-------------------------------------------------------------------------- Date....................................
a Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water-----------.----__--._..
�14 Test Pit No. 2...........
.....minutes per inch Depth of Test Pit____________________ Depth to ground water------------------------
----------------
W
0 Description of Soil/. ..__:__. '' ._ __
V ---•----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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 is e by the b d of ealth.
®Q Q l
igned. ---- -•.................... ---------- -- - --/ ---•-
Application Approved By......... FEy[ .... r - - -----•-•--- ../Z.
Dal �. .
Application Disapproved for the following reasons:........................................................................ .......................................
.................................----------------------------------------------------------------------------------------------------------------------------------------- -----------------------
Date
PermitNo.......................................-----------•----- Issued...................... .................................
Date
FEs......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEA TH
1
_.. .__ _.......OF... :..
Appfiration -for Bispmal Works Two4ritrtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System,
i
c� v � -- � -
.--•• --•---
------------
✓ Locati Address or t
yr.
---- ....
-- 1
W wner Address
-•--_ -------- --•-------------------------•------
p Installer Address /
Q Type of Building Size Lot.l___.. ..Sq. feet
Dwelling—No. of Bedrooms----_--__.- ------------
--------------Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons.--_____.-________---___---_ Showers ( ) — Cafeteria ( )
0.' Otllek fixtures ---------------------•--------
W Design Flow-----_: 0 x'!_________,_}_,�__._�__�____gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tunk—Liquid capac• _ gallons Length---------------- Width................ Diameter___... Depth
x Disposal Trench NaC�._ ,__. Wi h___ ______________ Total Length.................... Total leaching area........_-----------sq. ft.
Seepage Pit No..................... Diameter_______..______._.__ Depth below Cilet_._________ Total leaching area/_-._-..-_-._--____sq. ft.
Z Other Distribution box ( ) Dosing tank
Percolation 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__.-_.__--_---_-_-__---.
O
Description of S • -:_ (�'�
x ---------------------------------------------------------------------------------------------------------------------------------------------------------- .............................................
-------------------------------------------------'I= ----•--•--•-•----------------------------•--------------------------•------- --•------------------•----------------•--•-•-••---•----•-----------
U 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 Complia"nce has bee d by th ar f health.
igne - •----- --------
-----•-- ----•-
Date f Application Approved By___________ __ Dag �/
Application Disapproved for the follo' ing.reasons________________________________________________________________________________________
-------------•------ 1
Date b :
Permit No.............. = 1'=- Issued.--- 4,
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF EALTH
•
. .....1 ' t. t.....oF. .:.......... :. .1 .....:.. .:........_...
Q'rrtifirnte of Tomplittnrr �,,,,.�
T I IS CERTI That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
b --
Installer
at �� :: riArticle
=------ --- --•- ---------------••---•-••------------•-••---•---•••------
has been installed in accordance with the provisio o XI of The State Sanitary C e s descr•bed in the
application for Disposal Works Construction Permit No""' ........
dated.-..._ .__ .__ __________.
..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS RUED AS A GUARANTEE THAT TIME
SYSTEM WILL FUNCTION SATISFACTORY. '
r' DATE---./—/1-- Y i ----------------------------------- Inspector--- ; /_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF EALTH
FO - -------------•-------- .
No...
FEE_ .................
%spatial 0 k onstrur it Vrrmit
Permissio is ereb ranted-____
Y g ----- ------ =--- r't .G!d"�. .••-----..... .......... ................................
to Construe ('�) or .'air ( ) a ndividual Sew ge Disposal System
at No'---'�--- / R - ---- ---------
----------- ---
� -.• ;Yy' Street
as shown on the application for Disposal Worl� Construc lon Pe No._.� __.. .___ Dated..__ _. _V-_ -_ _�-___
Board of H th
DATE------�_ .._�"• .-
---------------•----_..__..
FORM' 1255 HOBBS & WARREN. INC.. PUBLISHERS
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