HomeMy WebLinkAbout0048 WOODBURY AVENUE - Health (2) r,
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD qF HEALTH
. ..........OF......
62� ... ....... ............
Avyliratiou for Uhipasal Works Tomitrurtion Vauld
4 ,100"
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
_y t at:
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-----------
............ ......./--- -------- ---- ----
catio'n- d or Lot No.
ess
............ ..................................................................................................
............ _—-----------------------------------------
................
0
nstaller Address
Type of Build' Size Lot.........................Sq. feet
U
Dwellin7No. of Bedrooms------- 9............................Expansion Attic Garbage Grinder
P4 Other—Type of Building ............................ No. of persons---------------------------- Showers Cafeteria
Other fixtures
De-sign Flow................. ...p"e'r,...pe,rso,n----per--day.--_------T---ot_al...daily'-...flow____..______....____.._...----------------------------_._____._._...__...gallons.
9 Septic Tank—Liquid capacity------------gallons Length................ Width.-__---._---_,-- Dian ter____-._-----__-- Depth_-.--_--_-__-._.
x Disposal Trench—No..................... Width... ..... leaching area-----
_?t !e, area-_-_._____________._sq. ft.
Seepage Pit No----------j-------- Diameter/gOLZY--- IYi- 1�el o LW1 inlet__..eet................. Total leaching�rea------------------sq. ft.
I
Other Distribution box Dosing tank a4W
Percolation Test Results Performed by------- .................................................................. Date f-------------------------------------
Test Pit No. 1----------------minutesperinch Depth of Test Pit____________________ Depth to ground water--_.-----.--_._.-.-_.__.
L14 Test Pit No. 2................minutes per inch Depth of Test Pit......_.......___... Depth to ground water-------____--________--.
.................................... ... ---------------------------------------------------------------------------------------
Description of Soil..........................
0 .................... -------------------------------------------------- -----------------------------------
14 S.-
U ..............................................................................................................................................................---------------------------- ----------
------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------...........
U Nature of Repairs or Alterations'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 been issued by the board of health.
--T'> -
Signed -----Y_.,M4,.2 4------------------- --------------------------------
VD :e
Application Approved By.. ............
...... -- -----ZT
ell
Date
,W te
Application Disapproved for the following reasons:...............................................................................................................
........................................................ ................................................................................................................................................
Date
PermitNo......................................................... Issued--------------------------------------------------------
Date
---------------------------------------------------- ----- ----------------------------------------------------------------
Ate.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH -
---... ...... :
Appliration for 15hipooal Works. Tonitrurtion Prrutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
ys
E
. ._----•- --5 *� '"• ..'o-- e ....
L ----------------------•------------
e L canon- d or Lot No.
Q--4i---resss—------------------------------------------
W O er �l Add
d AP. a'---------------
nsta er Address Type of BuildingSize Lot.. ....................Sq. feet
�-I DwellinNo. of Bedrooms.-_- ................................Expansion Attic ( ) Garbage Grinder ( )
a Other—T e of Building _____-- No. of persons____________________________ Showers — Cafeteria
Q' Other fixtures
d
W Design Flow..................; .........gallons per person per day. Total daily flow............... __ -- gallons.
Wx p acity............gallons Length................ Width---------------- Dia t ---------------- Depth__.-_______----.
Septic Tank—Liquid cap
Dis osal Trench—No.................... Width._: .._._____ �al- e 1 _ ._ Tot eaching area--------------------sq. ft.
Seepage Pit No.......... ........ Diameter/ : _.___. I t�6elow > et ..___........_.._ 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---------------------_-
(XI Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------
-
---------- ----------------------------------------------•------••-----•---------------........---•-•---•-----------------------------------------•---------
0 Description of Soil.........................................................................................................................................................................
x
U ....................................................................................................--------------------------------------------------------------------------------------------•-
W
VNature 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 board of health.
ned ................................
,r^- Date �a
0111
Application Approved BY-----t' Gam -----_ v Date ,
Application Disapproved for the following reasons:-----------.-------------------------- ........................................................................
-•••-•----•-••----•---------------------------------------------------------------------------------............................................................................-----_--•---------------
Date
PermitNo......................................................... Issued.........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAD . .
•• ...................OF.... s;
Tertif Yratr of Tnntph anre
TFI IS W CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
Installer
4—
has been installed in accordance wi�he provisions of Article XI of The State Sanitary Co ' descri 'd in the
application for Disposal Works Construction Permit No________________ _ __ __________ dated..dl;R�NTA
._...__ .__...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A THAT TIME
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................ .' ................................. Inspector------ ... ........................
THE.COMMONWEALTH OF MASSACHUSETTS
IBOARD. OF HEALTH
b. .. � ......OF........... ..
No.----- EE./f
F ..............
rtii exl�tt#
Permission is he�e y granted q ; -- - ---- --- - ......................................
to Constr '. ( or`Repair ,( )' Iiclividual ' Iewage D' osal System
treet
as shown on the application for Disposal Works onstruction Permit No __ ___. __.: . ated;_ __ �.........
- ............... - -- --- --------------------
~
v Boar of Health
DATE-- .
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS -.