HomeMy WebLinkAbout0041 PARKWAY PLACE - Health (2) yt �u ��
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD �i' HEALTH
_..... OF........ ....Q .-' ..............................
Apphratiun -fur 4tupuuttl Workii Tunutrurtiun Vrrul t
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System qJ
ion.Add Vs or Lot No.
Owner Address
W - � ._ � - -- --------------------- -
Inst 'r Address
Type of Building Size Lot----------------------------Sq. feet
Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ---------------------------- No. of persons._-...__-.-_____-_---__. -- Showers ( ) — Cafeteria ( )
Q' Other fixtures ---------------------------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length---------------- Width---------------- Diameter................ Depth----------------
x
Disposal Trench—No- ____________________ Width-------------------- Total Length.................... Total leaching area--------------......sq. ft.
Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area:.................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-------------------- ..................................................... Date----------------------------------.-._..
,al Test Pit No. 1................minutes per inch Depth of 'Pest Pit-------------------- Depth to ground water...------.-..----.---. -
Gz, Test Pit No. 2_______________minutes per inch Depth of Test Pit_. .........______. Depth to ground water...-.-_--__------_------
(�' -•-------------------------------------- .-- ----••------ -----•--•---•-••----••-•-----•--------•----•------------.-----
ODescription of Soil----- ---------- ••• -------------------------------------------------•---------------
x
U ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
W --------------------------------------------.......----------------------------------------------------•---••-•-------- ------ ----
VNature of Repairs or Alterations—Answer when appli 1 ._�. ... ........ ....... ..... --__.-_. __
'Lc ^
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 the board of h�lth. 9
igned- =' .../ --------
Date
Application Approved By--------- . ...... ....... •. • •--- -- -1 ' l -- - ---1�
l D e
Application Disapproved for the following reasons:--------------------------------------------✓ .,----------------------------•-•----.-------------- ---Date
PermitNo......................................................... Issued........................................................
Date
4 -• ��/
No. ...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Application -fur 43itipmal Worko Tonarurtlun Vamit
Application is hereby made for a Permit to Construct( ) or Repair ( ) an Individual Sewage Disposal
System V "�&
rogation-Add&ass or Lot No.
Y------------------------------------ -- -- ... ---------- ••--• ----------- --------------•------•-
Owner �`
_. � ..�.. - r •----- -•------•-•-•---------••-•-
Add Address
! ,. �-
Instadler Address
Type of Building Size Lot__.........................Sq. feet
U Dwelling—No. of Bedrooms______________________________ _____________Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures ---------------------------------------------------
W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length________________ Width---------------- Diameter----._.--------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length-------------------- Total leaching area-------.------------sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area.._____-._.___--_-sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date------------------------------..-------.
Test Pit No. 1----------------minutes per inch Depth of "lest Pit-------------------- Depth to ground water........................
Test Pit No. 2----------------minutes per inch Depth of Test Pit-- ________________ Depth to ground water------------------------
0 ----•------•-------- --------------- ------- ------.----- . .............................................................................
D Description of Soil--------- .......................................... �'r `--G------
x
x --------------------------------------..._._-...........................................................................z�__. I...----------------1../�. ---------------e.152......
_.. ..
U Nature of Repairs or Alterations—Answer when applicabl-. .-"--__� ' _______-
,�-" /'
--------------------------------------------------------------------------- 0T �. f�c�*'c ---- -
Agreement: 1-1
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.
Signed,-_ __4 ---_---- :7- .! /-(/2J•-------- -------------------------------
Date
Application Approved BY ..... !! .!�'.C -- . c .... «'
Day _
Application Disapproved for the following reasons:................................................................................................................
•--•--•-----•--------------•----•---•------------------------------------•-----------•-------•-----------
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
1;1 . :< ........OF...... .' ..1�1,!��x-' 4--........y.........................
0.1ertifiratr of feuntpliaurr
THIS IS TO CERTIFY, That the/Individual Sewagejis osa m constructed ( ) or Repaired ( )
by ------_:... � '<e� - . 7:6 � t�-
taller
has been installed in accordance with the provisions of article XI of The State Sanitary Code a .desc i'bed in the
application for Disposal Works Construction Permit No.___-_
PP P �� dated � -- esc i
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------------� •---' �G ----7�7--•-•----------. Inspector----•- -----------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF-HEALTH ,
1:............:.:..........OF........... Gt.......-t.......... ............. -- / ----
No......................... FEE----Af-�t..............
D610oottl ork (n n>�trnrti $t r
/! ---
Permission is hereby granted-- --- _ - -- n�.....'�`� � -...... /v..
to Construct ( ) ,o�Repai ( 'ran Individual-S,ewa'ge Disposal System ---------------------------------
at 2.�'�/t • _ _.--
No. ,f �!'` -v' .r �,..............................................., ' =
Street —7
as shown on the application for Disposal Works Construction Pe r No--------/-___-..��Da ed__�/_!� ... �..__.
Board of Health
DATE..... .....................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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