HomeMy WebLinkAbout0123 BUCKWOOD DRIVE - Health n
1
..f
THE COMMONWEALTH OF MASSACHUSETTS
-------:"1Z?4'11t-- - --- -- OF......... 172- NPI
Application is hereby made for a Permit to, Construct or Repair an Individual Sewage Disposal
System at: r
.......4.,.P. II,W C_//(W to* 0/ .. I*........ 6 .......... .....................................
7wher Address
Installer Address
1110 Other Distribution box Dosing tank
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 healtht
or
7 Date
Date
Date
Permit
. � Date
. __`-'---''''''_'' _ _'''— '_' ' —'_ _' _ _ ^-'^
i+ Jlip
No....... ....... Fs$............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...... ........ ..........................OF.........................................................................................
Apphratiam for Disposal Hlorkii Tuno#rurtion 1hrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
v
Location Adress
3 ..... _._ _ ___
�,�' E < r.. or Lot No
QL ....._... ...s•._.(iir-scd`7.w'is�....a...... .c._._•__
ar er Address -
........: _ .•......... ....................................•............... ............ ...._:_..... .......... ..... ..... ....•---..._._..__.__.__......._......_._._....._._....
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.........jrr:`::':........................Expansion Attic ( Garbage Grinder ( )
'4 Other—Type T e of Building ______________ No. of ersons............................ Showers `
a YP g -------------- P ( ) — Cafeteria ( )
0.1 Other fixtures ..................................................
d --•-••--•••••-•••-••••••-•••--••----•--•-••••••••••-••_____________•-----......_-----•
W Design Flow...... 1!................................gallons per person per day. Total daily flow__.... _;. .--------------------------gallons.
WSeptic Tank—Liquid capacity./..j�- }_gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No______________ ____ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No. _ __... Diameter________j �"$° ________ Depth below inlet......, :........ Total leaching area.................. 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-fo ground water................._......
fT Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
............. -•-••--•••._.........-••• .........................................................
O .:_.`.7
xDescription of Soil ,• ,w•< 1. -•-••---------------••---•-•---•-•-•------•-•--••-••••-•••--------------•-----•-----•-•-•-•-
•-------••-•________________
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,,
t"
„� - o
Signed--•--�' - ---•'•--.. ,:_.. t'.. ._.ate ;
J Date_«V
A lication Approved By `.
Date
Application Disapproved for the following reasons_________________________________________________________________________________________________________________
.._..---•....-•..............•----••-..._._•-----------_._____.__._-_.__...._.._......••-._._.....__...._...__.-•---•--•----••--•--__.___.___.__________..-__-_-_---•••••••---•-.________.__.._____......
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........................................OF....................................-................................................
Tntifiratr of Tout linnrr
THIS IS TO CERTjFY,1That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
J>f ,1
� � rf � r lnst,�ller •
at__ `- .r__... � '`r ................................................
has been installed in accordance with the provisions of Article Xl c�"The State Sanitary Code as described in the
application for Disposal Works Construction Permit No...... .��! 'Z
...............•--•----._ dated--••------ ------•------------•---•--•----•---
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�rf ....:...:....................OF... .................................
NO........, . ?..:_.... FEE,_. _,.................
Diapaivat Works Tomitrurtion ranfit
Permission is hereby granted .J.:....__t 'b-:._ ' ..<<... `�..�._.____. . __ .
- .......
to Construc4 ) or Repair ( ) an Individual Sewage Disposal System
at No.: !................ ..!'l_, ..._..._ ......_ :j it,-,.� '.......... � 1_.........................................
s _..... a' _...:.
Street
as shown on the application,for Disposal Works Construction Permit Nit., ',.,%,e......... Dated--- - :._ F_�
vZ/
................................. 2 -
F,, J
r lioard `I-lealthr •°" '''
DATE . �. ._'lf.....c........... - t
FORM, j455 HoBBS 47111ARREN. INC.. PURLISFIF.-R$ �