HomeMy WebLinkAbout0064 FOLSOM AVENUE - Health hi
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LOCATION SEWAGE PE T NO.
VILLAGE 0
INSTA LLER'S NAME i ADDREASG7
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ma" 02601
e UILDER OR OWNER
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D ATE PERMIT ISSUED.
DATE COMPLIANCE ISSUED
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF......../jam. I................
Appliration for Di"atial Works Tonotrurtion ramit
Application is hereby made for a Permit to Construct or Repair l�an Individual Sewage Disposal
System at:
......6 V
.... ..------- ................................. ..................................................................................................
location-Add4ess / or Lot
L"', 77�
... ....... . ...... .....
!.1j,.................. ...... ...5........... .. .............................
,jw r Address
............. .......................... ............
Installer Address
U Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms....................2
........................Expansion Attic Garbage Grinder
'-4
P4 Other—Type of Building ............................ No. of persons............................. Showers Cafeteria
PqOther fixtures ......................................................................................................................................................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
9 Septic Tank—Liquid capacity............gallons Length................ Width._........_..... Diameter.__..........._. Depth...._........__.
Disposal Trench—No. .................... Width.._..._............. Total Length.__....._........... Total leaching area....................sq. ft.
Seepage Pit No_____________________ Diameter.._................. Depth below inlet._..........._...... Total leaching area............-__-._sg. ft.
Z Other Distribution box Dosing tank-
Percolation Test Results Performed by........................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit..........._-....... Depth to ground water..__..............._.__.
44 Test Pit No. 2................minutes per inch Depth of Test Pit_................_.. Depth to ground water..__._............_.___.
P4 ----------------*-"*"*-,--------*11---------------------------------------------------------------------------------------------------
0 Description of Soil............. d M
�4 .....r------------------***-----------***--------------------*-------------------------------*----------------------*------
U ........................................................................................................................................................................................................
............................................................................................................... ...... I. .............. .......
.... --------- V_ .. ....... ....�.
- ------ -------------
U Nature of Repairs or Alterations—Answer when applicable...... .... ...4-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'JIT4 11E 5 of the State Sanitary Code—The undersigned further agrees not to place the system iW
operation until a Certificate of Compliance has been issue y the board of health.
Signed. .... ............................................. ..........................
Da
Application. Approved By. -------- _ L,........
--------------------------------
Date
Application Disapproved for the following reasons:.................... .................................................................................
...........................................................................................................................................I..............................................................
Date
PermitNo......................................................... Issued_.......................................................
Date
No.... 2=1 i F.Ric ...,�.'............
THE COMMONWEALTH OF MASSACHUSETTS
. BOARD OF HEALTH
........................... ..... ......OF ..... !�L w, `�,`.---..
Applirtt#ion for lliipuiittl Workii Tom3trur#iun Vamit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at: .,..4..
..........��. ......_�'�....-- �:S `'' '..... .............................. ...........••- -----......-----•------ ----------.......------........------
ocatron Addsess or Lot N,q
. .-.. . . `? � - ------------------ ......e .._� a. .S .:...... ...........................
0 r Address
a -------------- --- - ....................................
Installer Address
� ............................ f Type of Building Size Lot S q. eet
U Dwelling—No. of Bedrooms..............2................. .....Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ............................ No. of ersons.....__..._................. Showers —
a —Type g p ( ) Cafeteria ( )
Otherfixtures ----•••------------------------•-----•----------•-•----•---------•-•-•••-----•••••-•--------`•-------....•------•-------...._......-----•------------.
W Design Flow............................................gallons per person per day. Total daily flow__._........................................gallons.
WSeptic Tank—Liquid capacity............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 ( )
~' Percolation Test Results Performed bY.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fs+' f
O Description of Soil "Z0'} -•--------•----------------•------•-----------------------•------------•----------------- - .:.
txj ------•-------------------------------------------------
-----------
.---------------------------------•---------•---------- ---------
- -------------------------------------------- ......----------••--••---•-••�r� . ----
U Nature of Repairs�,or,�Alterations—Answer when ap licable_....e _ �... _ n3� _,+"' �".4 P--
Agreement: �f
The undersigned agrees to install the'aforedescribed Individual Sewage Disposal System in accordance with
the provisions of:T'11E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has,been issue y the board of health.
r.
Signed_'. `.. ... ................................................... --------------------------
Application Approved B - - . l Da e
Date i
Application Disapproved for the following reasons:---•-----•----•---•----------------•---••-------•-••---••--------------•--•-•-•----•----•--....------....•-----
---•--•------••------•----•--•---------•-•................•------.......•-----•--•-....•-----------•------•-•-•---•-•••-•--•....----•••••---•--••---------•-•••--•-------•-----••...------•-••----......
Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
`.v t
OF............. ................
�rr�ifirtt#r oaf f�nnt�littnrr
TH S IS TO CERTIFY, T at,the Individu 1 wage Disposal System constructed ( ) or Repaired ( )
nstaller
at......If.
40•• --
........�. ...... _._..�._./- •-- - 1....•. --•-----------•-----------•----------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No------- 2.~_ ?. ............ dated_ ......._._.______•-._.-......____............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATI, FACTORY.---------------•-------- Inspector................. _ ''
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
No... .z.� 2-.t�.. FEE........................
Biiiposal Vorkg Tnpi#r inn rrnti#
Permissionis hereby. granted.............................................................-----------------------•---••---------.....---•----....•-•-....................
to Construct ( 4-.cQRepair (Z�a dividual Se ya}ge DispJo' System
at No.---�! "c f_ �---'rr..---_4 t'()s^ ..... ,€1�
Street
as shown on the application for Disposal Works Construction Pernut No....................• Dated..........................................
•------•---------------------_
-� / BoayQ o ef+�iI alt
DATE......--•==3,/_-_!,_71 `,---•-•--------------•-------------------
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS