HomeMy WebLinkAbout0107 CHASE STREET - Health (2) ' 'Se
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_arstons Mills
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No, 4213 1/3 YEL
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No........-�- �� 1 �� .:
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
44
Appliration for Disposal Works C9nn#rnrtiaan Prrutit
Application _
lication is hereby made for a Permit to Construct ( ) or Repair (Van Individual Sewage Disposal
System at*
..-�/ ... ...���---777 •-- .........
e
.. .., o.... jA .-e........ ...................... ...... .....or Lot.No........................................_.
... .. . .. ... .. .. .. .. .........
i„ owe; Address
...................'..lr.........................Inst l..r......................................... ....................._.......................... re.............................................
� Installer Address
UType of Buildi g Size Lot............................Sq. feet
Dwelling No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
`W Other—Type of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures .
d -------------------------•-----------... ---------.............................
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 be?x ( ) Dosing tank
aPercolation Test Results Performed by.......................................................................... Date.................. .....--•--•--••-------
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.:_.______._____-_.____.
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-,__________-___-___-_--
--•••- -
Description of Soil...._.....__
•-------------------------------------------------------------------------- ------------------------•---•-••..-----
V 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 i,sued by the board of health.
F
Sign a
.---••-•-- •-• .• ..... ........ -----•----• --------------- ............D -te--•••-•-
Da
Application Approved By.........• = � ----------------------------------------
Date
Application Disapproved for the following reasons:.............................7------------•--•-•........••-••-......-••--•---............•••......:......
................... ------------------------------..... ...........................
.
_.
` Date
Permit No......................................................... Issued--� .-/-' ---- ------
Date
A..
No......Z...L ------ FEE... ...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.... ...... O1:.... y .........__------_--
.,Applirahon fvr Bigposal Norkii Tonotrurtion Vrrmft
Application is hereby made fora Permit .to Construct ( ) or Repair ( an Individual Sewage Disposal
System at: : r.: ....____.__.
r oca �1d tion or Lot No.
fess f/
.., .:.. cPM .....................
,n, .......e. .......................................
Owne Address
.................................................................................................. ................ ...................I..........................
Installer Address
Type of Build' g Size Lot............................Sq. feet
a . Dwelling: No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—,Type of Building ............................ No. of persons............................ Showers ( ) -- Cafeteria-( )
<,4 Other fixtures --••--------••-•••------•----•--------••--......•............ ...•----------------•-••--------•-•--•--•-----.....•-----•--------••..._••--....------
W Design Flow.........................:................:_.gallons per person per day. Total daily flow............................................gallons.
aSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter..._............ Depth................
xDisposal 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 ( )
`-� Percolation Test Results Performed by.......................................................................... Date.....................-••-•-•-••-•••----
a
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_._______--.-____-___--.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
----......._•----•--------------------.........................................................
Description of.Soil---------- "fit>. -. ...---••-•--•------------------------•---•-•-•------------•--•-•----------•---•-•••••-•-•••......--
V ......................................................... •....._--•------------_----------•---------------.........----••---......__-----•------------------•...........•--------•-•--.....------------.
W ------------- -------------------------------------`-- ........:.... -•-----------•----------------•-
- ` ---•--------
V 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 board of health.
ync� !
Application Approved B 1 fJ
PP PP Y....4 - r .. . - �..
r ate
aiw� `' .. Date
Application Disapproved for the following reasons:..---'................•--.....
--------•---..•------••-•....--•------••-•-•-•-----------------••----•----------
..--•-----------------------••--•---•------------•........__.-----------...---........_.............................:---•••---------------•---•-_.......-----.._......----------•----------•----•-•------
/{ ' r Date
Permit No.................... Issued ' ( °
.. ......-•..............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
* :.., ;r ! .... O F......` 3 .. ht"oc +R... ...........
''
Tr ifira oaf 11ut ftatrr
TH�I S T CERTIF ?Thayfthe ndi ideal Sewage Disposal System constructed ( ) or Repaired
I
Yt --- -- -----------••-•••-------......
at---- fad '' .r e+j°w , t! •----------•-•-----•-•...............
1 �� ----- •-•---------•--
has been installed in accordance with the, provisions of Article I.o T e State Sanitary Code a described in the
�..
----..._._ dated- - - .�--- --
application for Disposal Works Construction Permit \'o......_ ._...__ �_ __ _ _. � f�' _._ '��-__.._.__
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GU RANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..._' ,�.........--............................................................... Inspector.... `-°.�...' _....�,.;,. _�_ .{!: "
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH,
t
a" � ...:. oF......" ` . . . :: � .. ' .................
, ,.
a..-f._.��-........ FEE.. :...............
Permission is.hereby rante TIP; 4 ................••-•-.........................................•••.
to Construct ( ' ) or Repair, ., ° an Indtvidual SeN% m s osal', y e
at No.. _, . . �........................... ••••• ............
.
Street r a
as shown on the application for Disposal Works Construction /gro'
P i~. No. f,.. - Dated_.<'�f1 '12:-.a+� ..--
m
uardaof I-Ic filth
DATE--- • -
FORM 1255 HOBBS & WARREN. INC.. PU^LISHERS