HomeMy WebLinkAbout0002 BLACKBERRY LANE - Health (2) -z�3 - ham.
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THE COMMONWEALTH OF MASSACHUSETTS 4
BOARD F H LTH
.... -----...OF.... ............ .. .
�. Applira#ion for Dispont Works Tanstrurtion Vrrmft
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Application is hereby made for a Permit to Construct or Repair ( ) an Individual- Sewage Disposal
Syst
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Location re's e `/� Lot No. s
• . ----�----------------------------- �-- ------- -_ --- ---ate° ......................
Owner Address
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• ...... --- -...........•.._.... --•• ..... •-••-e--•••••--••--•-----•--•-•-- --------
Installer Address
Q Type of ldin Size Lot.... _ ............Sq. feet
Dwelling No. of Bedrooms...........X
.......__.__.=____.__Expansion Attic ( ) Garb g Grinder ( )
Other—Type of Buildin ____ No. of persons............................ Showers — Cafeteria
a' Other fixtures ........................-----------------------------------_---------------- ......................
Design Flow...................... a_---•_- all r rson per day. Total daily flow............._ -__�— gallons
W
-------------------------gallons.
WSeptic Tank-j�Liquid capacity --------gall Length________________ Wid h_. Diameter......_--------- Depth................
x Disposal Trench No..____j______________ Wid h.._____.._. ._ _'of otal e 1 ___ _.____..__._ Total leaching area ,.sq
Seepage Pit No. (.__ Diameter ._ ept b net Total leaching area_1Lsgd S_
z
Other Distribution Vorx ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date.--------------------------------------
Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water-.--___-_-__-_____--_--.
GXq Test Pit No. 2................m' utes per inch Dep h of Test Pit _................ Depth to ground water_-._-______-___-____--_.
9 ------ --------------- . -------------•••••• . ....................................................................................
d Description of Soil......... .. .... y"_-----_
UW ---------------------------------- -----Z `... ...G--- ----- ----------------------
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 ee issued by the-board of Zh,Sig ed.- •••• •• .-•---•.••--•. � " .......--
--------------------------------
Da
Application Approved By_______ __ ____ __ flL-
-
-----------------
' _, .. -_
ate
Application Disapproved for the following reasons---------------------••••-- ••••••...--............................................--------- ------------------
-•••••••••--•--------•-••-••••-••-•-•----•••-•----•-....................................•............................-----------------------------------------------------------------
------------------
Date
PermitNo......................................................... Issued........................................................
Date
-- l:
Nc.y
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
•�--. _„ ,ry
fW 1 ° add -- ..OF... `..... s � .............................
l
Applttatioaa for 15ispooal Workii T000trurtiou Errant
Application is hereby made for ja Permit to Construct or Repair ( ) an Individual Sewage Disposal
Sys!vo at
s
... .....*L /�Ae
� � d 4 P
No.Location SAd ess o rvvIof
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--t .....-. --
wner �A dress
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aW --• •• .... ..... ....... ••----•-•---••-................. ......................... -•--••--••---•---•......-••-•-•-•-•••••--- ............---•--•-••••............-•-•••--•-•••-----
`> L Installer Address
d Type of Bit my Size Lot.....: :.. ....�� q. feet
U
Dwelling=.No. of Bedrooms________________ _ _______________________Expansion Attic ( ) Ga°frba Grinder ( )
aOther—Type of Building -,,;_;:-_-__--___--I......... No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures ------------------------- - -
W Design Flow.......................... .....gallons per person per day. Total daily flow............ " py '"-------------gallons.
WSeptic Tank�Li uid ca acit sk 1 q p y_.� :.�°.: allons Length................ Width._ Diameter---------------- Depth__._________....
x
Disposal Trench—No. .................... Width... i..._. :Total ngth Total leaching area---. -_____sq. ft.
3 Seepage Pit No......... ... Diameter_. : __ el 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-.------.--_______-:-.-.
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.___ ------------- Depth to ground water------------------------
--------------
0 Description of Soil......
U -----------------------------------------------------------------------------------------•--•-•••••-••-•-•-•--••••••-••--••-•••-•-••--•••--•••............-•••-•-•••--•.... ...............................
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•--------------------------------------------------------------------------•--------•------•--------------------- -------------------------------------------------------------------------------------
-
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 Sanitar ode— The undersigned further agrees not to place the system in
li 4?
operation until a Certificate of Compliance has�bee5elissued by the:bd A of health.
Signed t. _ '` -- ------•--•------- --
t nl t Date
Application Approved B * �" ' . ► --------------- ` J' ' ... 3
APPlication Disapproved for the,f ollowing reasons-..............................t--------------------------------------------r--------------- --------------
Da t e
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.f ...........OF.......... ... +x,v, ,... ..........................................
Trrtif irate of Q.Tkoutpli4n r.
T IS TO.4LIERTIFY, That the Individual Se. age DII sposM System constructed ( Z101or Repaired ( )
y---- ...
x�` 1 nstaller ;+a
has'been installed in accordance with the pro ` ions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.... ......... ... ". ...... dated-._._-.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUAR EE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. J/
��
: DATE...... Inspector . ---..�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH,.,,
7 OF.... ..._
No..... FEE ..:1 .----
15ispoiial rk '11 diou Prutit
Permission is hereby granted ------ --- --- ------ ----- ~...
to Construct ( g"-pr Repair ) n Indivi Sewage/Disposal System
at No. - "" r ;� --- ------------
r J1 ,, r
as shown on the application for Disposal Works Cons,ttruction Permit .No ............ Dated... f
,a "3 `
s Board or Heath
DATE....................................................----------------------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS