HomeMy WebLinkAbout0020 ARBOR WAY - Health (2) a0 t3rr - "toi-vi 1 6
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
ir
Owner Address
Type_(2�� Installer Address
Design Flow................................. allons per person,Zpr��day. Total da, ow............................................gallons.
P4 Septic Tank-Liquid capacity . .. .�Allons Length--- ......Width----:7:� ....... Diameter---------------- Depth----------------
Z Other Distribution box ( ) Dosing tank ( )
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 hhas bbe iissuedl by theboard of health.
Date
Date
------------------------------------------------------
Date
Date
• � ' r �%
•. No---- ---------------•... ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
;,,.... ,
`jf .`.C•. .........OF..... ? ?` . x..::. "?is�!k ;e°!- � :�—a✓...
Appftration for Bhipwial Works Tomitrurtinn Vrrtntt
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at
...............................................
ocation Address or Lot No.
t - {^• _.Z--= '°.-j _ .lt Z_ --------------•-•-•-••••••-••-•••.....•--..._...--------------•-•--•-•--............•..._.........
F Owner 1 Address
. #- l 1 ) t t
_________ _____________ __..._...... ......................................................................................................._._____________._______._._____........._____________.__.._.__......_......__.........._..___
j' Installer Address
UType of Building Size Lot__________ ____Sq. feet
.-, Dwelling—No.-of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
pa, Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
G4 Other fixtures ......................................................
W Design Flow......................................... gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacit� 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_____________________-_-
�14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water____________________-_--
------•----------•------•--•----•--•••---•••••••---•---••--••---.....•---••--•••----••--------•--•-..........................................................
0 Description of Soil.........................................................................................................................................................................
x
U ............................... .......................................................................................................................................................................
--------------------------------------------------------------------------------------•-•--------------.............'------------------ --------------------------------
rJ Nature of Repairs or Alterations—Answer when applicable._______ ::?� . ? ,,, 1 , :_ �•___________________________________.-.
--------------------------
-- - �/-------
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 haZbDe issued by the board of health
Signed = `` i t -S ........
Date
Application Approved By................................'�;' x ' `'-?'"t.� �.
/� � ----
u/ Date
Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------
..............•---------•••••---•••--•----•-------•-•--••-••-----•--.•--------•-•-•-----------•-••-....•••----••--------•••------•......---------- -•--•--•-------•••-•-----•-••••
Date
PermitNo......................................................... Issued.-- ------------
ate
t
,THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD -OF HEALTH
.. ` t a
Zerttftratr of fT'luntphattrr
THIS IS TT9 CERTIFY, That the Individual Sewage Disposal System constructed (to"r Repaired ( )
A Instalherr f
�,,� -----........................
has been installed in accordance with the z�07isions of Article! I of The State Sanitarv.Code as described in the
application for Disposal Works Construction Permit No...... *� ?...................... dated_-, ____-_--_--
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS AJ�UARANTEE THAT THE
SYSTEM W FU TIO S1 CTORY.
DATE. ...... Inspector ( ------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS.
BOARD OF HEALTH
....... OF_,45_
No: ..__.. •.....
�i�����t1 �rk� C�nn�trtxr�tntt ernti�
Permission is hereby granted..... ...re -= ' r �r 0-----------------------•--------..................
to Construct ( ) or Repair, (&---`"an IndividuA Sewage Disposal System
at No.------ ---- y -
/7' f Street
as shown'on,the application.for Disposal Works Construction Permit No._I.1• ')______- Dated_____> _—.t` %'
>i
1t
•; Board of Health e
DATE-----'�: ��^ - .r° 1
FORM 1255 HOBBS & WARREN, INC.,'PUBLISHERS