HomeMy WebLinkAbout0059 WESTBURY WAY - Health 59 Westbury Way
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LOCATION , SEWAGE PERMIT M_O.
4�i1 I L L A G E
I N S T A LLER'S NAME. i. ADDRESS
® UILDE R OR MIER
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.��rATE PERMIT ISSUED
DATE COMPLIANCE ISSUED 9. 2y $y
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THECOMMONWEALTH OF MASSACHUSET-TS
BOAR® F H
1
ApplirFation for Uilivusaal Workii Pustrurtion ranfit
Application is hereby made for a Permit to Construct ( or Repair (, ) an Individual Sewage Disposal
System at:
- Location Address�� � U_ -"]e_ � or•Lot No.
........... _ _ ............ -•-• ........►.�---/--n •------••------------------------------
W ---------• -------------------- .ee -�i _..... ..........---- !�a�a.U: °� sit
a ........-••••-•...............
Installer Address
Type of Building Size Lot.20j... ___Sq. feet
U Dwelling—No. of Bedrooms............................................Expansio Attic ( ) Garbage Grinder ( )U
aOther—Type of Building ............................ No. of persons._.__.__________._____.____ Showers ( ) — Cafeteria ( )
Pa Other fi to s .•-----••----•------------------
W Design Flow............ gallons per person per-day.day. Total daily flow------- �_____________________...gallons.
04 Septic Tank—Liquid capacityz .gallons Length......
P..... Width................ Diameter---_____-------- Depth................
Disposal Trench—No..................... Widt ................... Total Length.................... Total'leaching area...................sq. ft.
ter.Seepage Pit No........../------- Diame ... 1 .......... Depth below inlet....16........... Total leaching area.V4?.(...sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by-••-------••--•--------------------------------------------•------------- Date.......................................
Test Pit No. I................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........................
--------------------
® Description of Soil /( �rJ --------------- . -----------------------------------
------------------------••---------
U '� ��— �`L •------------------ ---------------------
w
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 TITi U 5 of the State Sanitary Code The dersigned further agrees not to place t e sy em in
operation until a Certificate of Compliance has b n is a by e board of health.
Signe --•------ --------•-----........................................ � I0.....
Application Approved By--•• ........... -•-------------------------------------- ....... 7 . -
Date
Application Disapproved for th o110 g reasons:-----•--------••----•--•---•--------•--•------•--------------------------------•------------------._.........._
-------•-•---------------••-•---•••--------•.........---------------.......-•-------........-------•••----------------•---........................---•- ...............................................
Date
PermitNo......................................................... Issued_.......................................................
Date
No.f `f_ ?J.Zel Fins..:..'! .................
THE COMMONWEALTH OF MASSACHUSETTS',,
BOARD jPF HITeH
p
............. ...................OF.......... *. '�.._...........U'...... ...............................
Appilrtt#ion for Bispnstt1 WorksAomitrurtion Vamit
Application is hereby made for a Permit to Construct ( L<or Repair ( ) an Individual Sewage .Disposal
System at:
lc�
9y A
•---------- ._.._�... .......... ....... ........ .........
........ ............. {. .. y�......... o
......._..........._.._..._
Location-Addresses'" j \ ` )
` �:.�. ..�►! ." "r / '-r................. •• ..... ......... ... . �r .........................
or
O(vner
-- - ---
lInstaller Address
e of Buildin
U Type g Size ..._::_1..f3.i_ ___.Sq. feet
1 Dwelling—No. of Bedrooms.............. ................... ....Expansioji Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons...._....................... Showers ( ) — Cafeteria ( )
1 Other fixtures -•-••••••--••-•--•---••••-----••-•••.....................•----•-••-•-......-•-----• -- ••-•••---• • -••...•-•-••......-•-•-..........•••••-
W Design Flow........ .�.,...........................gallons per.person peg day. Total daily flow.__... ? . ..----------------------gallons.
WSeptic Tank—Liquid capacit/ _gallons /Length................ Width._:G......... Diameter------------ Depth.................
x Disposal Trench—No..................... Widt •...,................... Total Length..................... Total leaching area___.................sq. ft.
Seepage Pit No......... ........ Diameter:.... ._........_. Depth below inlet...1. Total leaching area....�_�. s . ft.
q
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by........................................................................... Date------------------------------------
Test Pit No. 1................mmutes per inch Depth of Test Pit.................... Depth to ground water-------------:..........
_ fT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Ri t
rt '°y41
Description of Soil ................................. --
................................................_..........................................................................................................................................•........_
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 TITLE 5.of the State Sanitary Code TV16t,
ndersigned further agrees not to place he sy tem in
operation until a Certificate of"'Compliance has been is b board of health.
Signed. � k'.... ...........
Application Approved BY . ......... _ =- .::..................................... •----7 - ............
Date
Application Disapproved for ;ollow g reasons:....................................................................................................-...........
...-----•-------------------------------------------------------------•-------------------------------------------------------
Date
PermitNo......................................................... 'Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
; BOARD,/;OF HEALTH
E � tg `n...........O F..... ✓ '.'' 'i~":� ....................................
C�rr�if irtt#r of f�unt�.�ittnr�e
THIS IS TO CERTIFY That the eC 'vi Sewage Disposal System constructed ( or Repaired ( )
by----------------------------- ......., .._....1, / �!>
�,1
fIn taller . ..............................................................
� f
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.4"112.0R.2 ............... da.ted_.......__:_._.:_.....______._...__..-----------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.... Z .` 61
......... Inspector......
....................................... ...................
THE COMMONWEALTH OF M'ASSACHUSETTS
BOARD�`tOF H AID°TIH ,r
No.............. FEE..:.................:..
nr�� ����#ruan �erutit
Permission_ is _ reby granted._._...:.:.�-' p -....._.. y1� --' 0�
••• ......------•....-••....................•----
to Construct ( �) for epai ( )�an Individual Sewage D is oral Systetxr =
Street
as shown on.the application for Disposal Works Construction Permit No----r ..... ...... Dated..........................................
� / --------------------------- ---- -----=--------------------•------------------------..._......._...
Board of Health
DATE.....................................................................
FORM 1255 A. M. SULKIN• INC., BOSTON
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