HomeMy WebLinkAbout0162 SCUDDER AVENUE - Healthr (j Ito 2 S
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ASSESSOR'S MAP N0. 5 'PARCEL ° �--
L0i> 0, N SEWAGE PERMIT NO.
VILLAGE
'Z>Q
I N S T A LLER'S NAME A ADDRESS
S U i L D E R OR OWNER'
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED ��
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........OF......
Appliration for Uhripus tl Works Tongtrnrtion Prrnti#
Application is hereby made for a Permit to Construct ( ) or Repair Individual Sewage Disposal
System at:
...........lk�..... .L .4:..^�. "----.... ` - ...... (�%s.SSc!C1.��...16�?N...................................
1
Loratio dress or t No.-� . Y . vim.... .
�� Own�erp Address
94
,....... ..._... ...........-•--••-•.... ............... ..••--
a --
pq Installer Address
VType of Building Size Lot.............................Sq. feet
Dwelling—No. of Bedrooms.._....................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q Other
fix
WG� fi xS=es .........................-------•-•-------••----• .
•-
Design Flow......._.. . t........................gallons per person per day. Total daily flow........ ga]l o-.n-_s-
SeptTank—Liquid capacity............gallons Length.... ......... Width......_.. ..... Diameter................ Depth................
.W Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching rea................•...sq.
ft.
x ...... Diameter._...I.�-..... De th below inlet.................... Total leaching area..................s . ft.
3 Seepage Pit No...... ....... p
Z Other Distribution box ( ) Dosing tank ( )
1-4 Percolation Test Results Performed by........................................................................ Date.........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
--------------------------------•----......---------...---------•-------.............•---•--•--------------
•------------------------------------------
0 Description of Soil.............................................................................
---------•......................•--•••-•.........._..........
V .........................••••-----........-•----••-•••--------••.........-------•-••••----......-•••-••--------•••--•-------•--•-••---------••------•-......-----•--------•...........-•-...-----•.....__
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 iI%'�% 5 of the State Sanitary Code—The undersigned further agrees n o place the system in
operation until a Certificate of Compliance has ny the b rd o he .
Date
Application Approved By............. ..................... �. 1: .....
Date
Application Disapproved for the following reasons:................................................................................................................
....................•-•••-•-•---------•---------...-•--------...---------.....---•--...--------•-•-------------------------•••--•----•---------•-••----•••----------------------------------••.....-•••-
Date
PermitNo..... ..................` .. Issued....................................................
Date
r .
No. .. . .Zz FEs �-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O F HEALTH
Appliration for Disposal Works Tonsirnrtion,prrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( Q -arr'Individual Sewage Disposal
System!!at: ,
(� Location- ddress 4 or Lot No.
...............!!
'24 � _.......------..... 1 �.:11: y. ._._.__... ._.._------------------------------------_........_........_............_........._
Owner Address
r ----------------------------------- ------------ - ��'.........................................................
Installer Address
Type of Building Size Lot:...........................Sq. feet
Dwelling—No. of Bedrooms........._Z.............................Expansion Attic ( ) Garbage Grinder ( )
`4 Other—Type e of Buildiff p., yp g ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
04 Other fixtures .....-------•--•••--- -- .11 Irl - ------------------- ----------------------- - ---
W Design Flow........ ..5........................gallons per person per day. Total daily flow_..__...� U..__-____._.___gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter_____.___.______ Depth................
x Disposal Trench—No_................L. Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No......d............. Diameter.__.._1..�n----- Depth below inlet____. ........ Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
14 Percolation Test Results Performed by.......................................................................... Date..........................:.............
Test Pit No. 1................minutes per inch Depth of Test Pit.........
_.......... Depth to ground water........................
1-4
fro Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a -•-•-------•••--••----------•-••-----•--.._..•------•••---•--•-------••..............................................{........-...............-..............
O Description of Soil................................................................................................................................................................
0....._..
x
w
----------------------------------•-••-•-------•--•••--••-•• ---..__.._._.---------------------•--------------------------•. ---=------- .
U Nature of Repairs or Alterations—Answer when applicable.______�''O.1D}__.___-.___�__�'"_�___--�V.'r_.---t_' / - ..__
_ --
Agreement:
The undersigned'agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not.-o ))"ace the system in
Operation until a Certificate of Compliance has been issued by the board o health.
C--�'" " r
Dat
Application Approved By--- =:; ...................... ........Z�_ . - -5 r
Date
Application Disapproved for the following reasons:..............................................................,.................................................
--.....•-••••.....................•--•--•••------------•---•-•----•---•-•--•--•--._..._..----_..-_..._...._..._._.....-••-•••--•-•---•-•-------••------••----•---•-------•-••••---••-••••-•-•---•----•--
Permit No..... �..< ....�.��_: _; Issued_ -Date......
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH`
�. ......OF C."V w S i G-b -E'.:_.:..................
(9rr#ifiratr of Tuoutpltttnrr
THIS IS TO.C.E TIFY_, T�I�he Individ al Sewage Disposal System constructed ( ) or Repaired
by
r+ nn Installer
at.. ?._ _.............. e -.------ttnN�Ll �.....................................................................
has been installed in accordance with the provisions of TITLE' 5 of The State Sanitary Code a§ described in the
application for Disposal Works Construction Permit No._._--acs z_____f__?_.?_=?..- dated kiNTEE
..���._���______.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUAR THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
!s,s�� j
DATE.. , 1•_ •..t `?�..........................•---....._...._...._. Inspector.........•-•!f'l-.--------
.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD_ OF HEALTH
� � zz............... ................... .... c
No......................... FEE........................
;Disposal Workii T-5rrns#rnrtian rrrmit
Permission is hereby granted--------- = -------•---�� mj _�" ..... a ---------------------------------------
to Construct ( ) or Repair (^--)n Individual Sewage Disposal System
at No
Street t
as shown.on the application for Disposal Works Construction Permit No��_---2Z---- Dated...j f_�/`��'................
c= i�- -----�
---- -` - —••--••-•---•---•-•------
` Board of flealth.•"r
DATE..-- �t1-O L� '
------•------ G�C�t �
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