HomeMy WebLinkAbout0036 BODFISH PLACE - Health (2) �c�zo /joc)
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_.....__ .. .... .... OF..................................... ........................................................................
����trtt#t�� $ur Ut��r��l �rk� na �#r�rtion Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
LXAd /2 or Lot No.
- •--------•----------•--••-------------- ------------------- ----...-----••--•--------•----•---_-...---•----
O ner "� Address
� Installer -- A---------------- -•-------•----•-•---•----------•--------------dd-----ress-------•-
(��G G�(--•
Q Type of Building Size Lot./.. O..............Sq. feet
U Dwelling—No. of Bedrooms--.-----�C_____________ --........Expansion Attic ( ) Garbage Grinder ( )
No. of ersons____________________________ Showers — Cafeteria per., Other—Type of Building _ ._���.___.______ p S ( ) ( )
a' Other fixtures _______________________________ __
W Design Flow-----_..............................._------gallons per person per day. Total daily flow----------------------------------------....gallons.
WSeptic Tank—Liquid capacity1UZ gallons Length---------------- Width._....--------. Diameter---------------- Depth................
x Disposal Trench—No_ ________________ ___ Width.................... Total Length- _----...____..-- Total leaching area--------------------sq. ft.
Seepage Pit No----- ....... Diameter____________________ Depth below inlet-------------------- Total leaching area-------.----------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.-_---------..-----_--
(� Test Pit No. 2................minutes per inch Depth of Test Pit---___--__-_._______ Depth to ground water------------------------
--------------------------------------- ----------------------------------------------------------------•--------------------------•------------•-----------
ODescription of Soil------------60,eft<�-........................................................................................------------------ ----------------------------
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 be issued by the oard
Zofal.thj
Signed.--- --------- --•- -••-• •-�-•'=-- -;------•-----•-•--••------- •�6--1�-�-Z?----�1--?.3
Application Approved B !� C =PP PP Y Date 73
-
Date
Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------------------------
--...--•••----•--------••---•....•••-----•--••----•-•---------------------•-•---•---•-••----•••••------•-...._..------ ---•--•----•--•---•-••------•----•-•-•----------------------------------__----_---
Permit No.---•7,?-1...=..................................... Issued...... -�� . 7
� �
D ----•Date-------•----
ate '-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_. ...... .OF..................................... ................ ... -
Applira#inn -for Uigpnotti Works Tonstrur#ion Prrutit
4Aication is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
c on- r n or Lot No.
W �y ner f`' w Address
a (�y .,.. ------
Installer 0e)A 4 a Address
UType of Building Size Lot_/a�_d Q�-______Sq. feet
Dwelling—No. of Bedrooms____4�
Dwelling Attic ( ) Garbage Grinder ( )
`a4 Other—TYPe of Building __________ No. of persons___________________________ Showers ( ) — Cafeteria ( )
d Other fixtures --•---------------------•-•--------------------
-•-----------------• ----------------
W Design Flow.............................................gallons per person per day. Total daily flow-----------------------------------.........gallons.
WSeptic Tank—Liquid capacity bU gallons Length________________ Width------- Diameter---.------------ Depth------___-__--.
x Disposal Trench o_ ________ _______ Width---------------------- Total Length-------------------- Total leaching area----- ____- -_____sq. ft.
Seepage Pit.No _ ------- Diameter _�__ _-_. Depth below inlet___________________ Total leaching area------- ----------sq. it.
Z Other Distribution box Dosing tank ( )
aPercolation Test Results Performed by----------_---- ......................................................... Date----------•-•-------------------_---._..
Test Pit No. 1----------------mtrlutes per inch Depth of :nest .Pit:-_:___.______..___- Depth to ground water-.-_____._-....-_____..
f14 Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water----------------------
---------------------------------------------------------------------------------------------------------------•------------------•-------------------------------•••---•------•----------------------------------=------•----------------••--•----------------
D Description of Soil------------ , 5 ---------------------------------------------
cxj -------- cc ' •••---------••-----•------------•---------------- ----- — ——------------ --------------------
v'
---------------- - ------ }• ------ ------------------------------------------------ ----------- -- -------------------------- -------------------------------- -----------------
-v
V Nature of Repdirs or.A.1terations—Answer when applicable__________________ ___-_--______-________-_______--_____-__-__-----_-__-----_-___-_____--
---• -----------------•--•----•------t-:----------------------•-------•--•---_-_-•----••------=-----------••---------•-------------•-•--------•---------------------___-------------------------------
Agreement:
The undersigned agree, to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article a ;he Sate Sanitary Code—The undersigned further agrees not to p'_ace the system in
r
operation until a Certificate11,of'',C:oinpliance has be issued by the oard ofa�lth
Signed. - d
'? l� Date
Application Approved B __-e__ — �0-- ---
P, 7.3
Date
Application Disapproved for the following reasons:........................................- ----- --------•--•------ •----•--------_------------------------------
-- ---------•---------•--••------------•---------••-----------•---
' !! Date
Permit No------{r•-i-----'----•-•-•--•••--•••-----•----•-•-_.. Issued.------•------------------------- to
Date ..._,.a
i
:THE COMMONWEALTH OF MASSACHUSETTS
BOARD. OF HEALTH
R , Trr#ifira#r of (tompliaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Installer
at-------- -r--'---------!7 ,
has been installed in acc _ fiwith the provis q � pf Article XI'of The State Sanitary Code as described in the
application for Disposal or s`: nstruction Per 1 � -------------------------- dated __-___l_h��°r_ _.�'
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FU C ON SAytSFACTORY.
r
DATL . " - --•-• Inspector_.-• ( .-."...-
�r Cf r
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF4,�HEALTH <'
-�? .
No. / FEE...............
Binpasal
Permission is hereby granted.......... 1...........-`�hllns-.....'----------------------- ...............................................
to Construct O or Repair ( ) an Indiv�fdual Sewage Disposal System
!. _ l=/ I> --------------------------------- ----
at No Df .
as shown-04'Nhe application for�I sp sal Works Consf� Be P n tetNo._._._7
r Dated --•-
rvr -- ---- ------
a '�Z Board of Health--
DATE-----------------------------------------------------
.
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
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