HomeMy WebLinkAbout0118 SCUDDER AVENUE - Health (2) `,� �51.1
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No.....K. Ftziic.2. ...
THE COMMONWEALTH OF MASSACHUSETTS .
BOARD HEA TH
y._0 F....... . ... ..... -----------------...........
Appliratiott -for Uiapoott1 Works Towitrurtion Urrmil
Application is hereby made for a Permit to Construct ( ) or Repair.( an Individual Sewage Disposal
System at:
............ / . --•-- --.....---•---- ..... • •• .... -•.. ...............................................
-
Loc tion dres or Zot No.
O Address
.
Installer Address
UType of Building Size Lot----------------------------Sq. feet
�-, Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
a, 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 ( )
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date---------------------------------------
,� Test Pit No. 1----------------minutes per inch Depth of Test Pit--._-____________.-- Depth to ground water_..__-____-_._-_-_.-___.
(4 Test Pit No. 2................minutes per inch Depth f Test Pit-------------------- Depth to ground water-..----_---___-.------_-
ix -----------------------------•--
0 Description of Soil-------------------------- ..... -
x
------------------------------------------------------------------------------------------------------------------- ----- --
U Nature of Repairs or Alterations—Answer whe pplicabl . .._3 .___._. :. . ...........:..........
--- - :- ----`--- -----------------------------------
Agreement:
The undersigned agrees to install the ,afore&scribed Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State Sanitary C — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be is edby tVIDqard of e Ith
igned... - .. -- --•-•- --.................
ate
Application Approved By---------- G Al
------
Date
- ��
Date
Application Disapproved.f or the following reasons:-----------•---••-•----•-------------•-•-----------•--•-•--•-..................................................
--......••---•--•-----•--••-•------•---------•------••-----------------------••--•-•---------............................................................
41�
Date
Permit No. Issued---- .. �--- . .� .............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEA TH
.O F......: .....
Appliration -fur Difipmai Works C owitrurtion Prrntit
Application is hereby made.for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System�t
----------- --------- -----• ---- ----- ---------------- ••--- • -•--••--•-•--•••------------------•---
Lo tion rclres or t No.
...............!: . .....-- ..................................................................................................
O 4;90V'' "f Address
Installer Address
Q 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 ( )
aPercolation Test Results Performed byw------------------------------------------------------------------------ Date---------------------------------------
,� Test Pit No. 1----------------minutes per-'tnch Depth of "Pest Pit-------------------- Depth to ground water-.----------------------
44 Test Pit No. 2................minutes per inch Dept f Test Pit-------------------- Depth to ground water........................
9 ----- ---- ----------------- ----- -----------------------------------------------------------------------------------
DDescription of Soil...........................--........... -----------------------------------------------------------------------------------
x
W ----------- ------ - ------ --------------- ------------------•••---------
U Nature of Repairs or Alterations—Answer whe pplicab '"�"� . .......
....... .....:... .....-
---- ---------------------------------------- ------------------------------ ------------------ .
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I of the State Sanitary C ' The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be is ed t and of, lth
Signed.... - - ------ -- ------ ---- --
te
Application APProved By '` ; - = �-
Date
Application Disapproved for the following reasons:................................................................................................................
------------------------------------------------------------------•---.........------••------
Date
PermitNo.------'== =-- -`"---•-.......................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
+G:�'`:.6�'`' l:... "
O F.......
. Cutifirate of T'nutphattrr
,
TH I D C TIFY at the Iijdividual Se ' e' Disposal;System constructed ( )'�pr Repaired;"( )
by..•-• •- ........ --- - ----- --
fInstaller. ......
---------------
has been installed in accordance with the provisions of Arti�clI of,The State Sanitary Cory s ibed in$tote
application for Disposal Works Construction Permit No..._IV .. . . . dated _ f✓ . .. �y
�`.. '...
THE ISSUANCE OF THIS CERT-jFICA,TE SHALL NOT BE CONSTRUED AS A GUARA EE THAT THE
SYSTEM WI L FUNeTION TISFACTORY
r� ,> AT1 s �Wn
r f
�• ... it
THE COMMONWEALTH OF MASSACHUSETTS
BOARD @F
a -
.
HEA��;
115
..................OF No FE .
Permission is hereby grante ---------- -- --- ... - --- -- - .......................................
to Constru ( ) Repair ( a Indivt tal"Sew e" ispl Sy
at No. ` `
treet
,.
as shown on the application for Disposal Works Construction No.... )ate
--�.._ ° '.., _._....
" r
alth =---
FORM 1255 BBS & WARREN. -INC.. PUBLISHERS - -
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