HomeMy WebLinkAbout0357 OLD STRAWBERRY HILL ROAD - Health �� 0 ��� v •� �-
�( �s o 0
t
�r
No.-- '._.__...... FEE..jam....:..............._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH , -
......... .............. -- . ...OF.................................:................................
Application is hereby made for a Peti-lit to Construct. (" ) or Repair ( ) an Individual Sewage Disposal
Syst at .
L•
tt i 4 p cc Lion Address or, Lot No.
...... Y; t trA e F:................... .......... � ....
ner Address
..... b .... ................................• ............._...................................................................................
W ,, : .a.
Installer Address
UType of Buildin Size Lot............................Sq. feet
.- Dwelling ' No. of Bedrooms............:~.'y�:........................Expansion Attic ( ) Garbage Grinder ( )
pa, Other—Type of Building --------------------- ----_ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ..................................
W Design Flow............. .r.gallons per person per day. Total daily flow..- gallons.
--------•----
eG Septic Tank�Liquid capacrty�� 1°_gallons Length................ Width................ Diameter---------------- Del3th................
Disposal Trench—No..................... Width............. -.... of ength......_.....__...... Total leaching area-----___....,_.......sq. ft.
Seepage Pit No---- ------ ------- Diameter_ _ sef'"De i�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---_------_-----.-.--_.
tq Test Pit No. 2................minutes per inch Depth of Te-t Pit_................. Depth to ground water__---_-__--_-__--_--_.
1:4 r�r-- �3-•
ODescription of Soil................ - .........................................................
v ......................................................... ••-•---•--•-•----••---•--•--•---------•-•-••---•--••---•---•.........-•--------..............................................................
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 issued by the board of health.
Signeel_ .........r-•---
---- •...
j
� .t Date _
Application Approved By......... _1 ors h' .. . .. 'y+~ •�
c -------------• -f �. -
ate
Application Disapproved for the following reasons-------------------------- ----.._.._...._..............._..._..___...._..................._...........
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAL H
�,. YX... .: v 't...............OF........ . , .... ........:........................
w5rdi iratr of Toutpliattre
THIS TO CF�2TIFY 'hat the ndividual Sewage Disposal System constructed ( or Repaired ( )
by. ., /�/ = ---•-----------•.--..... -----------
a tr Install
at_ •� E ' •fir 4 _.4a �` �f � "'". �
has been installed in accordance with the provisions c Article X of he State Sanitary Code as des ribed in the
application for Disposal Works Construction Permit No __........................ dated___ ------------
THE ISSUANCE OF.THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WiLL1fUNCTION SATISFACTORY.
DATE----•-•••--•.Gr ` --------------------------•-------- Ins ector..P_._f✓
THE COMMONWEALTH OF MASSACHUSETTS
BOARD A",
HEA1_T '
1
�ie'&^1.:....... OF........ ! ...... ...... ...............
No.... tT'"............ ..... FEE. .
—yurks u1i r
Permission 's ereby granted::
to Construe( or j}2epair ( ) an ndividu 11 _Sewage Disposal Sys
at No t'n - �=j---- a•a � ..s .�� �^, �. ;+ ............. ,��� .. t.........................................
r
141. ',Street
as shown on the application for Disposal Works Construction it N ated .; /_ _:,. ........
D � -.
'? Board of: Health Py
DATE...................... �
FORM'1255 HOBBS & WARREN. INC.. PUBLISHERS
No.._�_.v.__......... .................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....... ........ ........ ........OF................ ....................... .........
Appliratiou for lRoposal 19ork . (foustrurtion ramit
11
Application is hereby made for a Permit to Construct )!,or Repair an Individual Sewage Disposal
Syst ;e .
a : �, � -
.....................��)...—./..?.0.....................
...........
E,,1"a,;i7on Address or Lot No.
.... ;4t ..=.. .....e...........
................ ...... ........................................... ..............................................".. . ; iner Uress
................... ................ ........................... . ...........................................
Installer
Address
U Type of Buildit Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion. Attic Garbage Grinder ( )
Other—Type of Building ............ ............... No. of persons............................ Showers Cafeteria ( )
04 Other fixtures ...................................................................................................
Design ow....z........ ... gallons per person per ay. Total ow. �=
W Di Flow d Ttl daily flow._.........0_._........._......_gallons.
1:4 Septic Tank—Liquid capacity) gallons Length................ Width-__-____-___-__- Diameter.___.._......_._ Depth..........._._..
Disposal Trench—No..................... Width............. .. Length___.____._.......__- Total leaching area....................sq. ft.
.............. Diameter)! e� elow inlet._.......__.._.___.. Total leaching area..................sq. f t.
Seepage Pit No---- of
Z Other Distribution box Dosing tank
Percolation Test Results Performed by.......................................................................... Date........................................
a
Test Pit No. 1................minutes per inch Depth of Test Pit.__--.__-______-__-. Depth to ground water___________.-_.-__-..__.
Li, Test Pit No. 2................minutes per inch Depth of T t ----------------
Pit Depth to ground water____________.___._____..
--
0 ..................... - - ---------------- ----------------------------------------------------------------------
�4 Description of Soil ...=:-n-
U .........................................................................................................................................................................................................
--------------------------- ----------M----------------------------------I-------------...............................................................................................................
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.
Sig .•................................................................. ................................
'e Application Approved By......'ezx % ---------_-------
ate
Application Disapproved for the following reasons:------------ ........................ ..............................................
.........................................................................................................................................................................................................
Date
PermitNo......................................................... Issued........................................................
Date