HomeMy WebLinkAbout0051 JACKSON AVENUE - Health (2) �e-h vie .
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9f HEALTH
1- -............_oF....... ......... --------------
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
Syst it:
1 -
..... .. _ _.... ... .... ... ..... ... ........... • -••-•- > ....... .......... ..................................
oca ddress I/ of N .
............................. ./... .. .: .
n Address .
...........%, --------- ----- ..... ------......
------------•------
staller Address
Type of Building Size Lot............................Sq. feet
Dwelling"No. of Bedrooms.._.__..... Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ....................::...... No. of persons............................ Showers ( ) Cafeteria ( )
a' Other fixtures
W Design Flo .r............... _........gallons per person per day. Total daily flow........... ......W Septic
WSeptic Tani Liquid capacity gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench— 0. .................... Width.....r.....�5e
Tot L nut _.___. Total leaching area....................sq. ft.
Seepage Pit No______ ___________ Diameter.�P-lll!_--___ el in et_.----................. To 1 leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) s — f C .
aPercolation Test Results Performed bY.........t................................................................ 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--_._._---___________-_.
P4 ......................................
0 Description of Soil _
-----------------------••---•-•------------------ -•- •---• -- -------= .:-'� - ---- ---- -- ----------------------------------
v ------------------•-----•-•----•-------•--•----......--•-----------------••-----•-•-----.......--------------------------------------------- ------------------------•-•-•-------------
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 of health.
Sied . . •-••••......•-•••-... ................................
D
Application Approved BY r -------Le
--- 1�fe
........................................................ Date
Application Disapproved for the following reasons:................................. ---...___.....
..........................•-•----•-------------••-•-•----•-------------------------...................------•-•-----•--......---•----•••-••-•••----•---••-•---•--••--•••-•-••---••----••-•....._...-----
Date
PermitNo......................................................... Issued........................................................
.Date
WIN
No.- = - '��""`--• FEE c................
THE COMMONWEALTH OF MASSACHUSETTS
E®AR® HEALTH
, lP iration for Disprrial Works Tom union ramit
Application is hereby made for a Permit to Construct or Repair an Individual
Sewage Disposal
Syst t
.. C ................ ......
.. _
o ddre s t No
Owner Address
W
Installer Address
Type of Building . Size Lot............:.........I......Sq. feet
Dwelling-No. of Bedrooms......... ...........................Expansion Attic ( ) Garbage Grinder.( ).
p I Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures - ---------------------------- -
W Design Flo . ...............•__ ____: gallons per person per day: Total daily flow_______.___ _ _.....gallons.
WSeptic. Tanl 'Liquid capacity gallons Length_.______________ Width................ Diameter................ Depth................
--.
x Disposal Trench—No...-................. Width___ Tot 4Len4t Total leaching area....................sq. ft.
Seepage Pit No______ ____________ Diameter_ 1 ..,_...: Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank
a Percolation Test Results Performed by......................................................................... Date.........................................
Test Pit No. 1................minutes per inch Depth of Test Pit................:... Depth to ground water........................
/4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.......................
1:4 ..................................
O
Description of Soil..................................................
------ ,f je -•-• ..................................
x
U ----------------••-•--••••-•-•....---•--•-•••----•---••-•-•--------== - . --•--• •----••-•-•-••--•--••---. ••-•-•---•................................
w
VNature 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
Da
Application Approved B Date -
Application Disapproved for the following reasons-----------------------------•----------------------------------------------..-•-••--•---•. -•-•-------•..•....
.................•-------•------......------------•-----------------------------...----•-------•------------------••-•....-•----•--••---•--•--•••....-------•-•----•----•--•-•-•----------••---•-•••-:•-
Date
44
7
PermitNo......................................................... Issued......................-.................................
y Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF. HEALTH
, ... . .................O F..... .0. ' ...........
up rdifiratr of T pfin=
THIS IS TO CERTIFY, hat the Individual Sewage Disposal.System constructed (' " o Repaired ( )
by ._-•--- ;: r
� aller r"11 .
at ,' , -`
• �'
has been installed in accor nce with the provisions of Article XI of The State Sanitary Code as des ri, in the
application for Disposal Works Construction Permit No............. _*...4Z ..... dated.... .__ _ '_.____
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA A EE THAT THE
SYSTEM W LL F NCTI0 SATISFACTORY
a
4
Inspector �� ` `
DATE. . ........� ... . ...........41,11, --.........-•-••••---......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
y .�j/ ....r.....� :.......OF....... ..
No....-7MiC [ '.r FEE .......
Diapowd Works (gonfitrurt, n Virutit
Permission 's reby aanted....."•-----•-- =
....._
ldual age Da SysoConstru Re
at No..... --•--M..._ .... .--•-•-
t n,Indiv ea
..... . ... "
Street w
as shown on the application for Disposal Works Construction mit N
Aidof
ated. I.
f � f `
-s « .............._
oealt
DATE_
FORM 1255 HOBBS & WARREN',.I'NII�-Rz�SLISHERS '
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