HomeMy WebLinkAbout0032 SAINT JOSEPH STREET - Health (2) ���
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THE COMMONWEALTH OF MASSACHUSETTS
BOA D A%HE LL.4 rH-.1
Appliration for Disposal Murks
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
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..... --------------- - . . ----I-/ 'i�--------------------------------------------
Address
Z Other Distribution box ( ) Dosing tank ( )
~~ Percolation Test Results Performed by Duto------.----__-'
Test Pit No l................minutes per inch Depth of Test Pit.................... Depth toground water------------------------
�14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth toground wu/cc.--------
o4 --_- ......... water
`^ Description cf Soil-------------------- ...................................................
---''----`--`------'------------`---------`-----------`--'---`-`-'--`--`-`----------
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U Nature of Repairs orAltecztixns--Aoywerwheo .---._------_-----------------._--
----`---------`------------'----------------'-------`-------------------
Agroroeor: �
The undersigned agrees to install the aforedmcribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary o� � p6� the ��m �
nce
has
AbDthe board_of health.
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operation until a Certificate of Complia
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Dat
Application Disapproved for the following reasons:.......................................................................................................-------
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
.......... ..OF...... .� ... ........-
Appliratiaan for Disposal Warks (onfi#rurtion rrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System a�
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° Location'-A�dfes AC. y �° or Lot No
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O r ess
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Instal er Address
Q Type of Buildi Size Lot......................... .Sq. feet
U a.
Dwellin No. of Bedrooms-----------;;_;�-----------------------Expansion Attic ( ) Chi � &Wder ( )
a Other—T e of Building ..... No. of person ............................ Showers
G4 YP g P°.. ( ) — Cafeteria ( )
a
Q Other iixture�s -------------------------------------------------------- ----------------------
Destgn Flow............. .... „__._______-_._.._.gallons per person per day. Total daily flow____.___. gallons.
w ._._._. Width---------- Diamete�.�r .... nepth----------------
nep
W Septic Tank—Liquid capacity.._.._____gallons Length_.._.___ 1
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area--------------------sq. ft.
3 Seepage Pit No--------------------- Diameter.................... Depth 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__._-______--._•-..____-
�TA . Test Pit No. 2................minutes per_inch Depth of Test Pit.................... Depth to ground water--------------------
O Description of Soil- -------------------------------------------------------------------------------------------------------------------------
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U Nature of Repairs or Alterations—Answer when applicable.._____________________________________________________________________________________________.
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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 beefs.issued by,fete board,of health.
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Signed --- ! --•-- ---•'-•---------------- ................................
Date
Application Approved B
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Application Disapproved for the following reasons: ....... .............7______--_____.-______-_________-_-_-___-_-___V�__ _, •m!--.-
..........................................
....'-•'••'-•'---------•'•------•-•-•-----•-•----•---------•-'•---••.
..................................................................--------------------
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
1 ,
. .. OF......... . ... ...................................:.. ......
Qrrliluttie as �a�t 'rr
THW IS TQ CERTIFY, That the I 0[viduaVSwage Disp sa System constructV ) or Repaired ( )
b]r f••.7� srrc-.- I'?',ry�'t 3`c: `•-•---x".`---•y'*•' - - ..:a�w 4-----------------
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y7`wy,, /C ns
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�e w,� -t BAD d' �+y�,�q•,,��,._::�._ � .
las been installed in accordanc rthrlttie C�'ovislon of Ai' 1'eii of the p anitary Code as described in the
application for Disposal Works Construction Permit No.................... :_ dated.... ................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT E CONSTRUE® AS A G!WRAf417EaW THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE. Inspector__ _: a 1 ^ -, -/ -----------------------------
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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N r+ �•.� may{ 1�............... ..O F r�`a�t is --'J.,�Z--------
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Dis o,aial aarkli C�oulit iaaArrnl)o. R � EY g G��tPermission is hereb ranted_ _____ -._.-___ __ _ _
to Co struq or Repair (f, an In-IV. El Sewage Disposal System
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as shown on the application for Disposal ilrk Cot n Permit _._a g.. Date�L___ _w
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DATE==.................................................................................
FORM 1255 HOBBS & WARREN. INCt„'PUBLISHERS