HomeMy WebLinkAbout0030 AUDUBON CIRCLE - Health (2) fia dry born G- �--
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7 OSTERVILLE
= 07 S M E A D
No.2-153LGN
UPC 12134
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THE COMMONWEALTH OF MASSACHUSETTS
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BOARD . F H A H
..(-�� -'L... OF....... ..... ...... -` ..
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Appliratinn for lkii oiittl Vorkg Tontitrurtion Prrutit"
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage, Disposal_
S;,, te, t
- - .------
Locatio ddr ss or Lot No�
.�..._ --------------- --
_Owner Address
a .............. = � ------•••--• ----•--•-•••-••-----••-•-•---.......................•- ---------------------------... ------
Installer Address
Q Type of Building Size Lot----------------------------Sq. feet
U Dwelling—No. of Bedrooms.............. ------._..Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ---------------------------- No. of persons.--------------------------
- Showers ( ) — Cafeteria ( )
dOther fixtures -------------------------------------------------- .........................
W Design Flow................................. .......:.gallons per person per day. Total daily flow-----------------------------------.--------gallons.
Septic Tank—Liquid capaci _..-_..._gallons Length................ Width_.___._._._.... Diameter---------------- Depth.-.._._-_-.-....
xDisposal Trench—No- ____________________ Width-?--------------- Total Lengt4,_._,, -=____._ taWle rea___--_-.__.-..._____sq. ft.
Seepage Pit No.-___- --___-_- Diameter_--_•_---___- Depth below inlet_��__....t� tcluna area---------------...sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed bY---------- --------------------------------------------------------------- Date...........----------- ---------•-------
a Test Pit No. I----------------minutes per inch Depth of Test Pit----------_.......... Depth to ground water...-----__---.-_.--. --
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-..--.-.-_-.-_--__--_. -
----------------- ------ --------
0 Description of Soil-- - ------ -------------------------------------------------------------------
x
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 undersign d further agrees not to place the system in
operation until a Certificate of Compliance has bee &, ued by the board u f health. / 7
Signed --- -••-••-•••-•--- ._ ..... .- ................ 71-------- /
ate /
ApplicationApproved By--------------------------------------------------------------------------------------------- -- ---- .........
Date
Application Disapproved for the following reasons----------------------------•--•-•--•--•---- --•-•-.........--•----------•-•-----•----..........--------•--------
Date
Permit No. 7�o------------------------------------------ Issued---- -- . .....................
ate
No......... ----•-•• F>m$...,f� ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ,OF HEATH
Appliratinn -for 11,ipnr iat Workii Tutw#rnrtinn Prrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
;r+•'ate'���.+�a. '��X•(��.Id 1'•f �,t+'R� f n, � Y .�
.._.--'----- --
Location"-Address or Lot No.
--zl__,t_ r? t t � .: ..
x P 0.F� _ 1t a esner1 i+f r
.. ......... .......•ra'. ------'-• ..._..___ •-----------•'-•••••-••---•-••-•..._._.._---
•. �' Owner a Address
...................1.................................
Installer .______ .............................._._ Address...........................................
�
d Type of Building w, . Size Lot----------------------------Sq. feet
Dwelling—No. of Bedrooms___-._-..-___-=�_______________________Expansion Attic ( ) Garbage Grinder ( )
aa., Other—Type of Building ____________________________ No. of persons____.___________________-__ Showers ( ) — Cafeteria ( )
PI Other fixtures -•-------------------•-•---••••---------------•-•--•----------------------------------
W Design Flow___________________________________________gallons per person per day. Total daily flow---------------------------------------..-._gallons.
;r
W - Septic Tank—Liquid capaciI ^`___gallons Length---------------- Width-------.--:__.. Diameter----------.----- Depth----------
x Disposal Trench—No. .........----------- Width____-------------------- Total Length----- ...... Total le �l�i rea-.-._-.._-__.___--_sq. ft.
'
Seepage Pit No.....0-_:r_________ Diameter.. .. :........... Depth below inlet's '. `_fr�___Total leachin area--___-.-_--_-__.-_sq. tt.
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..--_--_--_-__---._-----
f14 Test Pit No. 2................minutes per inch Depth of.Test Pit-------_............ Depth to ground water__._.-______-__._-_-----
0 --
'Description of Soil_,-,_ __ �" a:r ",__� «'
x �, -- --------------------------------------------------------------
U ---------------------------------------------- -•'-••----------'•-••-"--••••••-•----•'--••••-•----------•-•--••'-•-'--'---•----•-------'---••••--------
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 issued by the board 4% health.
t r" 'Ff
Signed,...;( �r'°� � � •-.�
- ------------------•--• ------- u•••- e--------
r �ate
ApplicationApproved By-------------------•-•-------------------------------------------•------•-•-'•-----------•-•••'-
Date
Application Disapproved for the following reasons:................................................................................................................
Date
Permit No.--- --- Issued..............................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALT
wrrtifiratr Of W"I limplittnrr
THIIS YS 7;�� Tl ER F ', That the Individual Sewage Disposal System constructed (�or Repaired ( )
by
1 ` 7 Installerat
-•-
lam: ----••---•----- --------- •-_...__ '
has been installed in accordance with the provisions of Article XI of_T4e State Sanitary Code as described in the
application for Disposal Works Construction Permit No.-n...............l.....___C dated_._.±1 //_�� 71.................'••••-•-•-'
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT TIME
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
J ..-f.. OF `f a z ' t`1
No..... ="....... FEE..././l-
�i��n�tt"Y` nxk,� ( n�tr�tr�tn$t �rrntt�
Permission is hereby ranted_._.
to Construct Repairs( �) an I.ndiviZIual Sewage Disp'psa] System ��✓3
at No.- _f_.�. /'r�;/', - f' ( 3: - v __
Street
J% Y�� { �
as shown on the application for Disposal Works Construction Per',mit No... _:.____ _ Dated_______ ___________ _____________________
r.` lt Board of Hea
DATE..... ... /----------------------_------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ,
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