HomeMy WebLinkAbout0552 STRAWBERRY HILL ROAD - Health (2) :tea s� � u� ems, c�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
4�_.... .-.OF........ .. . ................................. ...
Applir ation -for Uiipoottl 10orkii Towitrurtion Prruid
Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewab isposal
System at
y.. ---1�......
L dd ss or Lot No. r—
----------
------------
Owner Address
W
a ........................... ............. Ins .....ler........................................ ........................-----..._...........Address............•. . ......•-•---
UType of Building �L� Expansion Attic Size Lot--G�ba e GrindSq. feet
Dwelling—Iv'o. of Bedrooms------------_________ p ( ) g Grinder
aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures):_-_-..________
Design Flow..................�U-.--------..._.__ allons per person per day. Total daily flow-__--_-_-_--__
W P P P Y• Y �-tl�---------------gallons.
WSeptic Tank—Liquid ca�acity_e�Lt ....... Width.-__---...-._.. Diameter__:_-..._.._____ Depth._.-____-._Disposal Trench—No. W Length__________________ Total leaching area_.__.__-_____..____.sq. ft.
Seepage Pit No..................... Diameter.... ow inlet_ _ ._ ......... Total leaching are--_--___-_.___-sq. ft.
z Other Distribution box ( ) Dosing tank ( ) d'�^
aPercolation Test Results Performed by........................................................................... Date...............__..-------_-_------._.
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water---.----__-_-_-_-._---.
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-----------.----_____--.
i -----
O Description f S - --- ._. ___`/�_ �� ._.__ 9
x �,
---------- -•-
4 -
UNature 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 ha en issued by he boaralth. �Signe .--- -- -- ----- -
Date
Application Approved By---- ---- --
------------------------------------------------- Date--•----
Application Disapproved for the following reasons:___.___.._ ______
---------------------------------------------------------------------------------------------------•..-----------...---.._..------------...---------------------------------------------------------
Date
PermitNo......................................................... Issued........................................................
Date
No. Finc
THE COMMONWEALTH OF MASSACHUSETTS
Y — BOARD 2IF ,.H EALTH
-- ..OF...... : /................................................
lirtttinu -lux IMBpuiial. urku C oustrurtion Vrrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Sys,t .a............ --- f ...._
� L ddr �s or of No. �^'*
Owner. Address
a •--•---•------- ................................. ..................• ------------•. ----•- -------------•-•-•-••---------••------•---•-• --------•---
Ins er Address
Type of Building Size Lot.... feet
Dwelling—No. of Bedrooms----- -------- --------- ------ Expansion Attic ( ' ) Garbage Grinder ° s
PL4 Other—Type of Building --._- ,----- ----------- No. of persons______-._-________-_____.__ Showers( ) — Cafeteria ( )
QI Other fixtures _
d ------ ---- -•--.--- ---- -•••-•-----------------------------•--------•,---- -.- ....-•-•-----
W Design Flow................Irk)------------
.. allons per person per day. Total daily flow............... ats -------------:gallons
WSeptic Tank—Liquid ca)tcity +'eons Lengt _____ ________ Width.. ..... .... Diameter_--._ --------- Depth.---
x Disposal Trench—No. .. t5-_P,. W t i......:....: .. Total Length-------------------- Total leaching area...............-- .-sq.,ft.
Seepage Pit No--------------------- Diameter___-___________.____ Depth below nlet_ -____ Tot 1 leachin ,area------------------ ft.
Z Other Distribution box ( ) Dosing tank ( ) � " .►'""�"i,
Percolation Test Results Performed by--- ------------------------------------------- Date =.----------------
a P P P a ; ---------------------
f� Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water_.---_..__.--_.____:---
,s� .¢ --
O Description of�So ` t/ r -
J
w a.
,v
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 \I of the State Sanitary Code—The undersigned•further agrees not to place the system in
operation until a Certificate of Compliance ha e n issued by he board alth
Date..,
Application Approved By.. -:- ----- ; ;. ._'- .......
.,.,..r'- i Date
Application Disapproved for the following reasons....... ..................... ........................_----. - _.--_--_----•_ _______ _---_-___ -------__
--•----......................................................
Date
PermitNo.......................................................... Issued.........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
.... ..............................
} Trrtiliratr of 0,11mplinurr
T S IS 0 CE IFY, That h Individual Sewage Disposal" constructed ( ' ) or Repaired ( )
bY------- - -- •.... ------ ... -
------------ • .../?.
In er
at
has been installed in accordance with the provi.' ns of A e I of The _tate Sanitary Co e as described m zhe
application>for Disposal Works Construction Permit No. : ........ ...................... dated .-_. ""A "7;
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT,THE.-
SYSTEM WILL FUNCTION SATISFACTORY.
> DATF................................................................------••--•---- Inspector------------------------------------------..---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
:BOARD F HEALTH.. ... ..... :. OF.._.
No.........X A.
i� u k uutitrurtiou Vrrmit
-
to Constru. or R I 1_ocdndividualPermisst t ... reby granted___ 1 Syat No. = • - ---- I = = ----- ----
Street .. � -----J ,,ft�"7
as shown on the application for Disposal W rks Construction Per ' o. ;__.. fIR _.h .....................
.......... --- --- >>--- --- •-------
Board of Health
a
DATE r '
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS -
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,bT BE uSC-c> To OeTEv-mi%4t= LnT Ltwe APPt_iGA1JT
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