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Home My WebLink About0028 KAY AVENUE - Health �,Ikcv�yve cQnfie rv;If C No.... - J_` _:. Fm&..... C,�...... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Allpfir a#ion for MgpoiiFal Workii Tomitratrtion Vantit Application is hereby made for a Permit to Construct ( ) or Repair ( A-)-an Individual Sewage Disposal System at: �J .. .. :. ----.-..---•.................. ••-••-.---.....••-=- .�'--•-- -..........---------...........-----_...-• . Location-Address or Lot No. — A Owner Address a .................................................... •-••--•-- ........_...•••--------'--•- Installer Address d Type of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( ) a~ Other—T e of Building __________________•_____--__ No. of ersons........_._.............__.. Showers — YP g p ( ) Cafeteria ( ) Otherfixtures ---------------------------------------•------------------•--•-••--------•--•---•-- W 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 are,�...................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........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water................... (X, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ODescription of Soil. x.. G ---- ...................... -------------------------•------- ------... ---------••-----•---------•--------- x U ••••--••••••••-•••--••-•-•--••---•---•••••--••.............••--•-•-••--•• . ... .....•-------•••••-••---------•-•••-••••--••••••----------•-••••-•-•----•••-••••••••......----'-...-••...••......-- ---------------------------------------------------------------------------------------•-•---------•--------------------------------------------------------- V Nature of Repairs or Alterations—Answer when applicable--------- ��r�______________ .................................. .__.....___. ••---------------------------------------------------------------------------------•--•--•---......----•-----•------------------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of I I i L p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issued by t e board of health. c� 2 SU Date Application Approved BY � •------------ �$._ d Date Application Disapproved for the following reasons------------------------------- ------------------------------------------------------------------•------------- --••••••-•••••....--••-•••-•-••-•-•--••••••-•-•-•--•-----•••••••-•---•--•--•---••-•---••---••-•••--••••--...-••••••-••-••••---------•-•-••••...--•-••--•---............................................. 7—fit` Permit No. Issued .�----- .................... Date '?c, ' 41� 1�,, , LOCATION. SEWAGE PERMIT NO. VILLAGE INSTALLER'S , �cNAME i ADDRESS R U I L D E R 0 OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED C. ,ri - THE COMMONWEALTH.OF MASSACHUSETTS BOARD ,�OF HEALTH ` I� � �............. OF.... ..... i..t . .................... (Infifgrate of Tomph aatre TH16 eIJS, TO (CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )�- by ''.... �::.. �`?..` f; --- - -----------Instah aA:4 .:�------------------•----•--•-.-----------------------------.------------- e- r has been installed in accor ance with the provisions of j of The State Sanitary C yde as described,in the application for Disposal Works Construction Permit No.-...: ..... " dated.... ......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WIIJL ,�FU ION A SFACTORY. DATE. ..: :... ........................... Inspector........ THE COMMONWEALTH OF MASSACHUSETTS BOARD-OF HEALTH, ............... ..OF....... - "s fr9a p a ..ro. No.......... `.... FEE ...:. :' Permission is hereby granted G'. = ..,. .. -------------------------------------------------------------- to Construct ( .,j) or. Repair ) an. Individual Sewage Disposal stem ................................................... Street _ .....................�........ as shown on the application or Disposal Works Construction Per No. ... :..... ... Dated.... ..�_�1._f''.°:�. (� Board of"Health r DATE.................................j.'�--/-----•----------•----............... {{// FORM 1255 HOBBS & WARREN. INC., PUBLISHERS �r •'.� k1 rr No................-....... FRs.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH, Appliration for Diopooal Workg Toaaotrurilon ramit Application is hereby made for a Permit to Construct ( ) or Repair (i 7"an Individual Sewage Disposal System at: - 7 �w.r ..!....: .. ........... Location Address or Lot No. Own� Address Installer Address UType of Building Size Lot............................Sq. feet a Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ------------------------- ---------------------------------•----------------•-----•-----••--•------•--••----------------.....-•------•--•------------ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid*capacity............gallons Length................ Width................ Diameter................ Depth....._.......... W 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 (. ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................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........................ - - f ------------- -- - ------- ODescription of Soil:!.".-�; z ..... -----f / ..y.0 a ------------------------------------------------------------------=------•--------------•---- V --•--------------------------------------•--•------------------------••---•-; -------•------------------------------------------------------------------------- ------------------•------••---- UW -•-------------------------------------------------------------------------------•••-------------•----•------------------------------•---•---------•-••--•------:..---------••-.....z 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 L T p 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. "� --- 1 Application Approved By...----- t� •"d�`� `„,'L' .... q .. ....date---6 ~...... "- Date Application Disapproved for the following reasons-------------------------•--•- ................................................................................ ------------------------------------------------••--•-•---------------••---- --••••------------•-•-------•----•----------- •-------••------- Date PermitNo......................................................... Issued-....................................................... Date