HomeMy WebLinkAbout0115 WHITE OAK TRAIL - Health (2) 115- ohlk O�t� mail, 6MI,
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No......................... Fim$..............................
LTH
THE BOARD AOF FHEALTH Ts
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11 Appliration -for 43hipmal Workii Tonti#rnrtinn Vamit
Application is hereby`made for a Permit to Construct (4 or Repair ( } an Individual Sewage Disposal
System at:
�" � " i o
.. Tmn....!Etkg_LQ.--•------------------------•--- +-
Location-Address or Lot No.
71-EY&EL I............................... ..........--------- •----...---•-----------•------------•------•--------
Owner
Address
••-- •-••....................•--••-••---•---•---
..........................•--•-•---•-----•--
� Installer Address
Q Type of Building Size Lot..;-3..5...............Sq. feet
U Dwelling a—No. of Bedrooms________ -------------------------------Expansion Attic ( ) Garbage Grinder (✓j
aOther—Type of Building ____________________________ No. of persons............................. Showers ( ) — Cafeteria ( )
Q' Other fixtures .......................................................
W Design Flow--------- ...........................gallons per person per day. Total daily flow.._.......3...��
.......................gallons.
WSeptic Tank k—/Liquid capacity/5.'CO..gallons Length---------------- Width_.............. Diameter................ Depth.___--._-.-._..
x Disposal Trench—No. .................... Width__..____._., Total Length-._-___----_____--.. Total leaching area--_---._---.-.-----sq. ft.
Seepage Pit No------I------------- Diameter./_ ._ Depth below inlet......r............. Total leaching area__-_...._._._.__.sq. ft.
z Other Distribution box ( ) Dosing tank ( ��
'-' Percolation Test Results Performed b .. _.... I? rl.n __.._..%,..<__.z5` ....I............... Date..... �/J -7__._..
W Y k �_�
�-- minutes per inch Depth of Test Pit..................... Depth to ground water....-----------._-...._.Test Pit No. --
�14 Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water_-._..---__-__.-__-_-_--
---___.__;_.._._.._ ,� -_-.__-___ .............� n_ G,
__._....__s_. __-___ _J� �/Description of Soil ,->$ -� 't '� `� = �'� �� � Vi t�
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 h een ' ed by the r- >ealth.
S.i g ":
Date
Application Approved By..--�/(fit _. � �s�1I - --------------------------- �� 77-----�-----^-`---------------------
Date
Application Disapproved for the following reasons-------------------------•------•-•---•-•------------------------._------•------------•------------•---•---------
..be7 r 16 V 7 L9 Date
Permit No.................... ....---- ................... Issued.. vvv
+t Date
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y
a
No........7' _._.... Fs$............................_
THE COMMONWEALTH OF MASSACHUSETTS,
BOARD Off, HEALTH
A.. � •.,.
OF
APPl rtttinn -fur Uhipoiitt1 Workii Tutu r,ur#iun Vanift
Application is hereby made for a Permit to Construct-;( or Repair ( ) an Individual Sewage Disposal
System at:
................r __.._ �fTx.._.0 ......TtA -....!C -------------------------------------------------------------------------------------------
ocati.n Address or Lot No.
Owner Address
................................................
Installer Address
UType of Building Size Lot_�2a_S ----------Sq. feet
�-, Dwelling=No. of Bedrooms-__ _______________________________Expansion Attic ( ) Garbage Grinder (00'
Other—,.T. e of Building ______ No. of persons____________________________ Showers — Cafeteria
04
d Other fixtures ..............................:_--•--------------•-•-------------____-•---•------------------------- -----------------------------------------
W Design Flow__........ '�_v._*_-...........................gallons per person per day. Total daily flow..._._ ,7 ------------------------gallons.
WSeptic "hanker Liquid caI>acitvl.S'" ::gallons Length................ Width_.-___--_- .._.- Diameter Deptll-._...-__..- -
x Disposal Trench No -_ .______ Widtli__ Total Length____________________ Total leaching area--------------------sq. ft.
Seepage Pit No iI.__ __ Diameter/' e-_ Depth belo inl t____ ______________ Total leaching area..-. sq. ft.
z Other Distribution box ( ) `` Dosing tan�`
`-' Percolation Test Resul s Performed b - __,tJ *^ Date "* .._ _..
Y - --------� _ .�s�' :------------
Pit No. 1_ ___ ________minutes per inch Depth of Test Pit................. Depth to ground water------.--_-___--__-_ . ,.
C7, Test Pit No. 2................minutes per-inch Depth of Test Pit.................... Depth to ground water__-----_____-______-_-
a ' E --------
-1
p
Description of Soil______.. _•�.�_�_.-_ .�_ •
{
V -------------------------
-------------------------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 een • ed by the boar health.
.�0..;), !,....................... . ... ....P..
Si
- Wes` Date -
,l ,,lication;A• roved B y/jf
' Date
Application Disapproved for the following reasons:----------------_..........................---.....................................................
.............
ell,
--•-••-•-•--•----•-----...-•-•-------•••---•-----------------
Date
. ri.. r
SPermit No---------------------................................. Issued........................................................
Date
--"'ter,
THE COMMONWEALTH OF MASSACHUSETTS
x, -BOAR- , HEALTH
. ......:.oF........
... '. ........-... .
err#iftrtt#p of f�uut�itttnrp
THI IS TO ERTI Th t the Ind dual Sewage Disposal System constructed or Repaired----�z- ( )
by- ----• --- .........
--•--. -- . - - ----
- - ------- -
�� r tiler a -----------'V_... ..�!t----
has been installed:in accordance with the provisions of Mictr XI of The State Sanitary Code as described in the
application for'Disposal Works Construction Permit No. .7p _______7Yk-_____------- dated _/r1_ .. ..` _ ______________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS.A GUARANTEE THAT THE
SYSTEM WIL FUN TIO-N SATISFACTORY
DATE78 .----,-- ------------- Inspector ���� .......................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OE HEALT .
7Z Cl .OF.........,��Gr.-S-..: o
No. --•-------- FEE---- .........
i� u tttvXk ,nuns#rur �on Prrmi#
Permission is ereby granted'"---- --- ----- ... - f-.. --•......... ....................
1------- --------•--•-•-•------ ='---•---•---•-----
to Cons uct ( r ep r ( ) an In wt al S a sp A] s m , tj
Street..
as shown on the application for Disposal Works Construction relit N � r y�
---- Dated..-•If.'/� 7
all
..-'6S✓'
/� � ��• k.,• ` Board of a }i
----- --.
{ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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