HomeMy WebLinkAbout0053 WALTON AVENUE - Health (2) ��,Kv�o .� �1� � o l �
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No......a-.../....... J 6 � Q G F�s... ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD QF HEALTH
....OF........
Application for 13isposal Works Tnnt=ividual
umit
Application is hereby made for a Permit to C?nsrut t ( ) or Repair Sewage Disposal
Systemat: ... .......... .................................or
ocation A ...... .... ............................................ Lot-No..........................................
wner Address
................................... .... .................................. ..................................................................................................
Installer Address
UType of Buildi Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers
a YP g ----•--•-••--•-------------- P ( )--- Cafeteria ( )
dOther fixtures .-----------•-------•--.....---••--•------------------•-----------•..._...-----•-•••-•--------•-------•-----••--••• -•----
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
W Septic Tank—Liquid capacity............gallons Length................ Width------------
_-- Diameter......_......... Depth................
x Disposal Trench—N Wid�h ........:. . .. L h ... Total leaching area_._ sq. ft.
Seepage Pit No.._._._ - Diameters .
5 /// th w inlet..................-Total leaching area... ..........sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by-•-•-----••-------•---•--••••-•................••-•............---•-••... bate........................................
Test Pit No. 1................minutes per inch Depth of Test Pit............._...... Depth to ground water__..__-_----__-___------
44 Test Pit No. 2................min s per inch Depth of Test Pit.___............. . Depth to ground water........................
a' ---------------------••----•-----------------•--------•----------
O Description of Soil........... _ -------------------------------------- ---•-••••---
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 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 ' s y the oard o a
Signed... . ........ ....... .......
ate
........
D
Application Approved By------
.. . .
ate
Application Disapproved for the following reasons:............................•--• ...............................................................
...........................................••---••--•--•-......••••--••--................--•-•---•-•-•----•••-•-•-•------•---. --_------------ .......................................................
Date
PermitNo......................................................... Issued.......................................................
Date
(
c '
No. l'. . ....... F�$...�1...............
THE COMMONWEALTH OF MASSACHUSETTS
{
BOARD OF H TI�
__.._. . ..... ... ........ OF....-.... '.. r ''
Apphr tion for =ividual
Application is hereby made for a Permitto Construct .( ) or Repair Sewage Disposal
System at:
I ,AV
Ex''+i!t, sj, :r ............................................................
r1 Xca.iou-Ag°1rreSs ((O((())))),,,/// or Lot No.
.E4 / ..
wner .Address
W .......... l... :..............•...... ........................................................
Installer Address
Type of Building, Size Lot_.........................Sq. feet
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 x ..t Xotiil L t1 F Total leaching area Y i Sq. ft.
Seepage Pit No...... .......... Diamete .., ._. iSe w m"'T�et_.__..._. ._,_..... Total leaching area. S " t
z Other Distribution box ( ) I Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1......:.........minutes per inch Depth of Test Pit.------------------- Depth to ground water_---.__._---____--.--:..
11, Test Pit No. 2.................minu es per inch Depth of Test Pit............... Depth to ground water........................
O ----- --- ` a
Description of Soil ,-•I -w'... �' *'Y ---------- ---------------------------------------•-------•----------
x -�
v .................................................
0 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 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 boat d of heal.
Stgiied j, .:_eirt R ..... '
li u eV Date
Application Approved By-----
` te;
Application Disapproved for the following r,.rayons:._______________________________ -
/
..................................................m................... .......................................................................... ...............................................7.....
Date
PermitNo......................................................... Issued........................................................ '
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD Q�F HEALT J
1 �. .........................................
Trri"firFair of (Samplianu
THA I ., CE I..Y ,.hat t�W `dividual 'age Disposal.System constructed ( ) or Repaired ( `
I al
at• �� ' .. - •-�'--i--- .- 1�_e�.... .r �'' Vote r
has been installed in accordance with the provistons°"of Article I of The State Sanitary Code a described ' the
.ram.
application for Disposal Works Construction Permit No.___.__.__ dated.._...:',... }
PP P f s
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT RE CONSTRUED AS A GU RANTEeTHAT THE
SYSTEM WILL FUNCT N SATISFACTORY.
DATE..... ��' •-- - 0? ................................... Inspector. .` ' ,...... ...-...............
THE COM.MOKWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
rF
OF
No........ ...... FED = .,,. .........
Permission is hereby. ranted ., 4;i::----- ._ ZZ4 .f` gip......_'........
to Construct. ) gr R°epai�. n itidiv.1 uai Se«vage-pisposal System
at No.••• f
`L�r:: �.="�''� '.S..r=-• a� '"�'a•--- .P� ��`." ..:��c`'�-d>t_��!fy: �.a�'a7... .. ..feyrsf,.�.
. . Street
as shown on the application for Disposal Works Constructio Pe ni No.. P......< _ ated.._-:.. .....
'r
44.o f ,
r v �
do>_tal
DATE ------- ---:......---.......... ..._ '
FORM I255 HOBBS & WARREN. INC.. PUBL!SHERS
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