HomeMy WebLinkAbout0062 AUTUMN DRIVE - Health (2) C� � Or.u.-I�c�.�n n `�ri���
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA
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M Appltratinn for Btnpnoal Norks Tonstrurtinn runtit
\� C Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
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P� N location- ress �r ir.al2o,,
..........:.`=�!4 ... ---�tl�..... �:_`!Sd.... ........ .... .............................
Owner Address
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Installer Address
Type of Building Size Lot.t.V/ /�— Sq. feet
Dwelling o. of Bedrooms--___-_�............................Expansion Attic ( ) Garbage Grinder ( )
`4 Other—Type e of Building No. of ersons--------------------•--•--•- Showers
Aa YP g ---------------------------- P ( ) — Cafeteria ( )
a' Other fixt es . -------------------------------------------------
W Design Flow. ...._..._..._._gallons per person per day. Total daily flow..........
WSeptic Tank—Liquid capacity(/-v_Cigallons Length................ Width---------------- Diameter................ Depth-_.--_---------.
x Disposal Trench—No_____________________ Wi __ Total Length............ ...... Total leaching area--------.-___.--.-�-,-�-•ems . ft.
Seepage Pit No.-r•__•_•--_______- Diameter. ��_... Depth below inlet__............ Total leaching area_s3_d_�_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...-- ______--_-_-._-.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_--____-_---____-__-....
a ---------------------e--A.......... .............................................................................................................
0 Description of Soil:--------"-.............v ._ "
x
W
V Nature of Repairs or Alterations—Answer when applicable.._---___--_-•-------------------------•-__-_------__-•--_----._-__--.--___--..-_--_-_--_----_
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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 of health.
Sied ..................................................................... .................................
Application Approved B
Application Disapproved for the following reasons: e
-----------•--•----------Date-------
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% ----------•----•-------------•----- __------------
, - Date
Permit No......................................................... Issued........................................................
Date
Naa,d FE>a.....2::...................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® HEALTH
- .. ... ...OF...... ff
_ flPt�
, ppliration for R-spn iat Vorko Tomitrurtion Vamit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
S stem at ,
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y 4ocatron-AfNress a �r d y,G or p 1 0.
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W / Owner Address
Installer Address
d Type of Buildin� Size Lot./t _1_' :. -______Sq. feet
Dwelling-{SrNo. .of Bedrooms___.__--_-:r............................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type, of Building ________________•-___.------ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures ----------•-------•-----------------------------------------------------------------------------------------------------------------------------
Desi Flow..................._ __...t= gallons per person per day. Total daily flow_______--- � l=—
W � `^�- --•-•----------g P P P Y• Y -��==%�---------------gallons.
WSeptic Tank—Liquid capacity✓ _V 'gallons Length----------------- Width---------------- Diameter________________ Depth-._._-.-_.--_._.
x Disposal Trench—No.................... Width- ._ Total Length............ Total leaching area--------------------sq. ft.
Seepage Pit No.: ________________ Diameter'(� _ x_i ..'Depth below inlet....... ..... Total leaching area_, tt: q, ft,.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed bY.......................................................................... Date---------------------------------------
a
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water_._-_-__-____-__-____.-.
FL, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_-______--.-----__--__.
P' ••--•-••--------------................
Description of Soil--------"`"..------------- -�� � ------------------------------------------------------
U -------------------------------• ......•••----•---••-•--•------••-----•--••••••-•---•-•--•-------•---•-•----••----•••-••---------------------•---•------------ ---- ------------------
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------W
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 Compliance has been issued by the board of health.
Signed ., 1 --- -------------------------•-----
-------------------
F f Zate
Application Approved B -`d _ F: f f
Application Disapproved for the following reasons-....................'---••-••--•-----------•••----------•-----••----•---•--------•--•......._......-----•------.
--•-•-----•-----•---•-------•----------------------•--------------•-•-------------------•=-•----...........-------•---•------•-•-----------------------------------•-•-----------------------------
Date
PermitNo......................................................... Issued........................................................
4. •n"" Date
t
THE COMMONWEALTH OF MAt ,SSWCHUSETTS
BOARD OF' HEALTH
+, 1 X y d rl
. .. ... � ..........O F..... . ..,r4 4t�,o .....................
�prtif ir�tr �f w���t�1i��rr
THIS IS TO CERTIFY, That the Individual .Sewage' Disposal System constructed ( ) or Repaired ( )
by �`•~ -----------------------------•---•-•-----
P.
+o Installer
at ' °
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has been installed in accordance with the provisions of Article X I of The State Sanitary Code as described in the
application for Disposal Works Construction Permit 2, 10k-------------_-_- dated.. � .: .:---------------
THE ISSUANCE OF THIS CERTIFICATE SHALL. PLOT BE CONSTRUED AS A CVVAiR/
ANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector_—, ..........��.k' ;�J .............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 0!57HEALTH
NO ..16'1.... FEE
Perto Consmu Sion is or ebe air nted........
an I ividu------------------------------------------------------------------ .........Yg
p ( al SeerDisposal Syst
at
i`�;.--- •- -- ,r ----------�-- Street �''--.,J ✓-•As shown on the application for,_Disposal Works Construction Perrpi�,No._._ Q*/-.___. D"ed___. j_�f
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_. �.. „y`--. c. >i... 'Board
r
DATE=-
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��FORM 1255HOBBS & WARREN, INC.. PUBLISHERS ��^