HomeMy WebLinkAbout0048 CEDRIC ROAD - Health (2) 5 M E A
No.2-153LY
UPC 12934
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SUSTAINABLE
FORESTRY
INITIATIVE
Certified RberSourcinp
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No...... _ Fmic..............................
h THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA TH
e— t7;r - ------ . ............. ...........
Apph ration -fur 43ispuua1 Works Towitrurtiutt Vrrutit
Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal
System ' f'i' /f
j Location dd ess Lot No.
�-`------------------- — � r
O ne Address
---- ---�Installer -- --------------------------
� Address
Type of Building/ ��V// -- Size Lot----------------------------Sq. feet
DwellingL No. of Bedrooms.-.-__,. _______________________--Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Other fixture
-- ------------------------ - - ----------------------- -----
W Design Flow..................... .......Vallons per person per day. Total daily flow-_---_ .................gallons.
W Septic Tank Liquid capacit}�040_gallons Length---------------- Width......... Diameter__-_---_-.----_ Depth................
x Disposal Trench—No ____________________ W;VV
_.___ ._! :�l Length..............._.... Total leaching area.--_-.-.-:..........sq. ft.
See a e Pit No.-___--- Diamete _ Depth below inlet-------------------- Total leachin irea.-__-.............sc ft.
z Other-Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date-------------------------------------.---
,� Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water..--_--..-----.--.-.---.
(i Test Pit No. 2----------------minutes per inch Dept of Test -t____________________ Depth to round water............._..........
---•-------- _...... -• •--••-------.... -------------------------------•.....---••-----
Descriptionof Soil - --•-- ----- •• -- ------------- �----------------------------------------------
x
W ----------------------------------------------------------------------------------------------------------------------- ............................----------------------------------------------------
U 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 no to place the system in
operation until a Certificate of Compliance has been is ed by - o rd of health. %�.
Signed-- - -
Daty Q
Application Approved Byd� ���✓-�, •-•--- .�Gd�� .� �G� ---
Date
Application Disapproved for the following reasons--------------------------------------------- ----------------------------------------------------------- ------
-•-••---------------------------•-----•--•-•----••••-----•-------------------•-••••---••---------------------•-••--------•------.... ------------ ---:--------- ---------- --------------------
Date
PermitNo......................................................... Issued---- - -.------_-----------..............
Date
THE COMMONWEALTH OF MASSACHUSETTS - -
BOARD OF HEALTH
.:...................O F .hr .................
"Tertifiratr >af T mphattre
THIS IS TO C,IE�RTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
by...................... ---f------- -
- i Installer q
at._? % .. !, =_ �� ``' -•--•------- f,� l?/ c= �---•------ %:rz-`f' '---•------••-•----•--•-----------------
has been installed in accordance with the provisions of Article XI o�,, -The State Sanitary Code as defscri 'ed in the
application for Disposal Works Construction Permit No-----�_.. �°_--------------------- dated----------------
THE ISSUANCE OF THIS CERTIFICATE SHALE, NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WIJ.L FUNCTION SATIS ORY J
DATI✓ <P Inspector �r �''r� r`C�.a
. r ak., Y �� Ff b.' eK° - +h..�r ., F�^t N.�F ! k s�,+�Nq,w+� - •..._Y. �..�.�,
rarw-w��e;dir'.3.r S:_�ixv�y.cu-_��:.��..-..x«..�ti.a....-.,�ti.....•✓�... ...,_ti r_o 4w,�._....»_.s,,.:. _•.,.-.._,.2... _._ �-.._-. _ _f'"�� .
�e',d ►�lrtinM�'Rak7�4ctY:;!�it'akx+F....• � - L
THE COMMONWEALTH OF MASSACHUSETTS
.� r� BOARD, Of f7 HEALTH
� d��
, L71v �...'.O F-- `%' '^hc.✓ G 4 L!C,...............•-------.. .... �l -
g f✓`
No.-- FEE__.- .....
Big olialV,�r
i Qlamitrurtion rrrmitPermission is ereby granted.............. ` t✓ tr e-- - - - ----
to•,4Const uct o e. air f an/,ndividual. ewa e Di oral S stem ry�i
( P ( ) ��'{' g P Y f'
at No y" s .�.... ..... r ( A.'t�. .Pn �? ---- --------
Street 2 ��-
as shown on/thheaplication for Disposal Works Construction P it o-__Q./._. . d_._.___...�1_ ________________________
------ - - •-- •--• - - - H. ��2-ram---=
------------
and of HealthDATE--••---• �---•- ------------------------------------
FORM 1255 & WARREN. INC.. PUBLISHERS f
A
A�
No......3-_7_�.... F��.....t�Z --�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF !HEA
Apptiratinn -fur 130poliat Works Cnnnwtrnrtinn Verntit
Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal
System '
0Y-. .......
,)))) Location.-.I.
` dd ess�s/�
•--____ __......... ........ G7/I IG.' A.................... .. _�____.'!---"_•:-�!=T_r •_•_____....__:—.�v¢. _.._':-mod 16rt�_�/-�
O ne Address
Instal Iere� Address
d Type of Buildi g Size Lof----------------------------Sq. feet
U Dwelling�No. of Bedrooms----_-: ----------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons.--______--_..-_____-___--__ 'Showers ( ) — Cafeteria ( )
Q' Other fixture
d _ -----------------•----• -----•••-• ..�
W Design Flow..................... 0--•- • _ allons per person per day. Total daily flow______ .........gallons.
WSeptic Tunld—Liquid capacit}w-'____gallons Length---------------- Width------- ........ Diameter---------------- Depth.-..___._-.-----
x Disposal Trench—N . . Wi th_____ �.___. al Length-------------------- Total leaching area--------------------sq. ft.
3 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. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water-----------..-.-------..
Test Pit No. 2................minutes per inch Dept of "Pest it-----------__._.---- Depth to round water-__-_..--__.._---_--.--.
�+ ............. .•-- ..............
............... ----------------_-----
0 Description of Soil-------------------------- �'. ✓ ------------------
x
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 \I of the State Sanitary Code��—The undersigned further agrees no to place the system in
operation until a Certificate of Compliance has been is Pied bathe board of health.]
%
Signed- - U-, C� -�_''�'_.................
p Dat
Application Approved By- . ....- --Awr�
- �----------_ ".
Date
Application Disapproved for the following reasons_............................................. __________________________________________________________________
------•-----------•----•-•..................•-----------------......•--•-----•- •-•---•----------••-------•--...-----•-----•----•--•--------._..--------- --------------- ------------------------------
Date
W �
Permit No. Issued...= -------------------------
Date