HomeMy WebLinkAbout0153 BUCKWOOD DRIVE - Health lS� 0--sucktooud a., 14zlcwqlS
No.----/-3J---•--••-• FEeR P,a.�.............
THE COMMONWEALTH OF MASSACHUSEETTS
BOAR® OF HEALTH
.. o
� i -� ttt-t Applirathut for l iipoal arks Tonstrur#t n �er
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: L
Location��}}dress or Lot
........L.U,.��,e .lL:P........ .!T....� ....t.............•.. ......,., .J'�.....'.`�leesra ....................
•--......c�..............................
Owner Address
CDlti rxuci/oAl
Installer Address
UType of Building - Size Lot............................Sq. feet
.-� Dwelling—No. of Bedrooms.....3...................................Expansion Attic ( ) Garbage .Grinder ( )
Other—Type of Building No. of persons____________________________ Showers Cafeteria
A' Other fixtures •............... ...................... .... `'
WDesign Flow........... ..............:..........gallons per person per day. Total daily flow........... ......_...............gallons.
WSeptic Tank—Liquid capacity_AQl_gallons Length................ Width................ Diameter................ Depth____.__________.
x Disposal Trench No. _:.______•_ Width____._ __........ Total Length.................... Total leaching area.....................sq. ft..
Seepage Pit No 0 _ --�_�iameter/..i.r._ Depth below-inlet.................... Total leaching area..................sq. ft.
Z Other Distribution bo# ( ) f Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
a 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........................
-----------------------------------------------------------------------•--------•-••--••-..._..•--•-.........................................................
0 Description of Soil.................................................
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 issu.50 by the board of health.
Signed....X -i.l. --� '�--'` - ' � ..........
/ y TSate
Application Approved By---- = �j.:l....
Date
Application Disapproved for ae following reasons____________________________________________
•---._�- --- -/ Date-•-•--•••••-•-
Permit No.......f�-�-.�6.'....................................... Issued.-------..
.....................
Date
a 4 z
. F$s� ............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..._... ........OF.......a'Y. A i ' .3 1, e t::..._-
Appliptiun for 4%ivma1 lVarko Tomitrurtion Vamit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: r
4, .......................................................fT,r
....^ r•--'-•--•._ ' ............................._......._ ..............:. •---------......_.........._....._...____.
Location Address �„ or Lot No.
............. ..............si du,�Fs 4 .....�''r ?. ` yE � ..........................
}Owner ...., Address ,._.... ...
..............IA �'e ...........5 �: i !t;t f f/ ....,,..... ... .,........................_................._.........
..... ...
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms_..... s.....:............................Expansion Attic ( ) Garbage g Grinder ( )
PL4 Other--Type of Building .............._------------- No. of persons----------.................. Showers ( ) — Cafeteria ( )
G l Other fixtures ......................................................
W
Design Flow............ ..A:._..:...................gallons per person per day. Total daily flow..........' _2......_---------------gallons.
9 Septic Tank—Liquid capacity...Z&Y)� allons Length................ Width---------------- Diameter................ Depth................
1 Disposal Trench No. .............. Width.... .......... Total Length-----_---____._--__- Total leaching area....................sq. ft.
Seepage Pit No..�.. °... ..... meter!c ,�_. .. Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box`r( ) '•' ' Dosing tank ( )
aPercolation Test Results Performed by-----------------••----•--------••---•------------------•----•---•-----.. Date.....................................
Test Pit No. l................minutes per inch. Depth of 'Pest Pit.................... Depth to ground water-.--.--_--------_-_----.
4-1 Test Pit No. 2................minutes per inch Depth of Test Pit.-_--._-_____-.-- _. Depth to ground water---_._--_________--._--.
Q+' ----••---••••----................-..........................................................................................................................
_ Description of Soil--------------------------------------------------------------------------------------------=-----------------•--------•-...------•-•--•---------------------•--•_•-•---
U ......-•-••--•-•-•-_.-•-• ! . •-• -•--•-•..................._--•-•........_------•--
W 4 _... -
--•----•-••-•-------•------------------- •---------•------------------==-------------------•------••--•-------------=---------------•--•---.--------------------------------------------------------------
V 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
I. Signed .xy_., q ���a_z; < `� !'-�z�lf._._' -_.��` ......... ... ..............
Date
< »Application Approved BY ... ----fi p� ----•--------- •-•-•-•--•---•--•-•-•-------•-•--•---
SL/ Date
Application Disapproved for thefollow ny reaso,
Date
PermitNo. -••............................. Issued........................................................
F C .. ate A% .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF' HEALTH
r t
....... OF...... 4 .vj r : . ,� k
3r v` t ,:.:. ................ ...........................
( n ifirate of li cr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by,..... .r r. r ----- -- --- --------- --------•••---............._...------------•----........_---••_......'
Listaller
K f
has been mst'alled in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit itio.___ . -., ........................... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. T
.---•-----•----••••••------•----•--•--•-•••--
.._ ............
��
DATE Inspector._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............... .................. OF.
{ J ' 7,✓ t G. r ' t ^.............................
NO... FEE........................
Permission is hereby granted .... ...................... .....................................................
to Construct( )� or�Re air ( ) an Individu li Sev�age IIispos system
at No....': _. ..:.. .. ................. '.:_ :._ .......r�... 1 �l .:
Street
as shown on the application for Disposal Works Construction t No. Date- ............
Board oT Health
DATE------.... . ................. ..........................
FORM 1255 HOBBS WARREN, INC.. PUBLISHERS