HomeMy WebLinkAbout0333 OLD STRAWBERRY HILL ROAD - Health 3� �. b� �I, P��
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD ®F EALTH
_OF...............:. - ... ........
Applira$iolt for Bhipoiial Works Tnnstrurtinn 11mud
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Systern at
'Location•Address or Lot No.
•Ifs O er.r........................................ ..........•.................................Address...........................................
Installer Address
U Type of Buildi Size Lot.. .........................Sq. feet
Dwelling No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( )
a� Other—Type of Building No. of persons............................ Showers
g ---••-•-•••----------------• ---• --- ( ) — Cafeteria ( )
d Other fixtures . ----••......•--• .............•-----------••-•----••-•--••-•--•-
.
- --------------------
- ----------
W Design Flow_____________________ � llons per person per day. Total daily flow............................................gallons.
WSeptic Tank Liquid capacity dons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No................. ... Width........ ._..Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No. ................ Diamete Depth below inlet.................... Total leaching area.............. ...sq. ft.
Z Other Distribution box { ) Dosing tank ( )
Percolation Test Results Performed bY------- .............. ................... Date........................................
Pit No. 1................minutes per inch Depth of Test .....
Depth to ground water._-____---__--____-__.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Description of Soil �� G�
x
U ................•--------------•••......--•-
W
x ------------------------------------------------------------------------------------------------------------------------------------ •-----•---------------•••••---------------•--•--••----------......
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 ZI 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.
i ned...
Date
Application Approved BY --• •.
ram. ......��3
Application Disapproved for the following reasons:--------•------•--------------------•--..._...._.... Da
...................•---------•-••------•----•----•-----..........._.._.......-•-•----.....•-•.....--•--••------------•••-••--------------•-...--•-•••--------•---••-•---•----•-----•--•....--- .........
Date
PermitNo......................................................... Issued................... ................................
Date
P.. ..........
No../ /� yr:
-_
_-- ............ Fnic.....Z�....................
.. THE COMMONWEALTH OF MASSACHUSETTS
ARD OF�)j
TH
Applirativa for 15isllosai Works Tonairurtion' Vvennit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at. y
t
Location-Address or Lot No.
r'
Address
....................... . Address
...... ....................................... '. .•...-•---...................-•----........
G0
Q Type of Building/ Size Lot............................Sq. feet
U Dwelling No. of Bedrooms..........::" ..............Expansion Attic ( ) Garbage Grinder ( )H .....-.._...
W'4 Other—Type of Building __--_.-__... No. of persons............................ Showers
g -••-•••--------• P ( ) — Cafeteria ( )
QOther fixtures -• - --------------------•------------ -----------........---------------------------- --- ............
Design Flow.................... . 6,4 ��_.,, lions per person per day. Total daily flow----------- e ._.gallons.
WSeptic Tank Liquid capacity,I lions Length................ Width................ Diameter---..__-___-____ Depth................
x Disposal Trench--No..................... Width................. .... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No. ---------------- Diarnete>r,�.f���. epth 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........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.......................
---- --•--•--- -------------------------•-•---•-----------------------------
'
O Description of Soil----••••• ! r /� r ' -------------------------------------------------------•------••----------
U ......................--.......................................................................................................................................................
W
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 YI 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.
Sinned .
t
Date _
Application Approved By............
'. -,fir
Da
Application Disapproved for the following reasons:----•-•-----------------------•-•------- ------------------••••••••••••-•-•----•--•-............-•••-••..----•-
..........••-•-••••••••••-•-•••••••••••••----._...••--------•••••................
.............................
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF,,- EALTH
...............OF....... �' '• w<.:.. .".
C"prtifiratr of ToutpiialaIM
T I 'IS TO RTIFh-Y, hat the Individual Sewage Disposal System constructed ( or Repaired ( )
by `• , - -
�y /f: 1tS 1 Ct .I 11 ✓$
G�Af�^ ��a S f
has been installed in acc .dance with the prop i_,ions oft ticle FYI of The State Sanitary ode as d scribed in the
application for Disposal Works Construction Permit No---------------- - ------------ dated day
THE. ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.............../ ' �'� — Inspector .e� ._ -
.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEAL7Fe# �w
� :. : ''t' .O F.... t' ,,ft �" �r '............. y
NO....._...... ...: FEE... .: .........
uisvqa IV or
Permission is hereby granted......... �...:.....................
ti, �- ., .....................
to Constr, ct r epatr a I divi ewa Disposal Systerh
is�'v� ',:/;-• � ••'C'
treet' •
as shown on the application for Disposal Worla Construction hut_ No. nl? tied_.__ ----l. ... __." ..
.................
i ..
Soar of I.ea i
DATE..................................... ......................................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS