HomeMy WebLinkAbout0075 ELLIOTT ROAD - Health (2) -7,- er-�k r 0-� 'R(�
,06
FRE.2V
THE COMMONWEALTH OF MASSACHUSETTS,• I
' I BOARD OF HEALTH -
1OF ..... -- -- - ----------
1 .... -
Applira 40n" for* � as il'� park `Cn �t�#� s �gi
.� Applicarion is hereby made for a Permit to Construct ( ) or Re air ( ). an Individual Sewage Disposal
s System at:
f - 4�
{ + Loca' n•Address `, vzr:��_
* ,or Lot No. '
C�r
w Addrt;ss. r
t,
er r Address "tea
d Type of Buil* - �' Size�-Lot ......... ...........Sq. feet
Dwellings No. of Bedrooms_:..-.>.-.: `_i:............'-_....Expansion Attic ( ) '� e Garbage Grinder
Q, Other—`Type of Building ---.f -------------- ------ No. of•persons..-------------.------------ Showers.( ") = Cafeteria
a r I '
Other fi es ... .. '.
W Design Flow: ............... ... '. ons per person per day. Total daily flow.-.. :..............__ .gallons'" {
' .r
W Septic Tanl�Liquid capacit�.. .-_..'allons Length--�_�Ial
..- Width`_-.. .-_-.. D', eter................ Depth.__._-_...: .
x Disposal.Trench—.No.............:....... Wi -. al 1 c ling area.........._..__.-..sq. ft.
Seepage Pit Ne-. :. Diametey P To 1 le
1.+ j3T{ t sc ft. ,
z Other Distribution box ( ') Dosing tank,( ) 1///✓04 � , �� �J
Percolation Test Results Performed by---------------------------------------- ----- Date_---....-•....-._-.......___._-....:._.. e
- ------- ------
1 Test Pit No. 1----------------minutes;per inch Depth of "Pest Pit..........._._--.-_. epth to ground water.----._.-------------
...
f1 Test Pit-No. 2----------------minutes per inch •Depth cA Test Pit................. Depth to ground water--------.._.._......_.
� '
L�, _........-•... .... ....:. .......
Description of Soil----------------------------------------------
- --- - ---- -'L. - ---•--•-------•--. •--•---.....--•---------------
W C
----•-`---------------------- -•-----------------• "----.-.---_--------------------- ------- --------
VNature of Repairs or.Alterations—Answer when,applicable_---------------......`'`_.....---._......-_......._.......-..__..------.__.-..--....._._.. '
R `
-----------------•--•--•----• ••----•----------------- •-------•------------------••--------------------------•------------•-------•--•------------•-------•-•-- --------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual eSewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned furthe agrees not to place the system it
operation until a Certificate of Compliance has bee ' sued by the board of
------------- ----------- ---------------- -----•--.�ID
•----
1 cApplication Approved By -• �---------- ---- -- -- ----- --e-Application Disapproved' .or the following reasons-------------------------------- = --------------------------`-------.----- ---------=--`- ---
�, ---
.....................•.... = ---------;---...---•----------------•----------------•...........-----------------•---------------------------- -------------•------•-•••-•--
i Date
PermitNo.-K..................................................... -_-= Issued......................
Date
A—
No.
..2. �V
� Fsa .............
THE COMMONWEALTH OF MASSACHUSETTS
-t- EOARD�F)HEALTH
....... OF...................._ ........ ..........._.....---------.......
Appliration -fur Digpuuttl Works Towstrurtiott Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at* , ( �
---------------------- ---- ---'•--- ---.f�'•--'------=--•------'-•- ------.----- -------•-------- -------or Lot IVo.--- -----'-"----•------
V 12 Location-Address_,>,-__.� Jlr�j---- - --- ._l/�'., Ti% 1/`f',•,r�- s---�---/" "
W �_�/ �!f �Ownd Address
d Type of Building,," F Installer/ a 1 -SAddress
d rLot.......... Sq. feet
Dwelling No. of Bedrooms...._...... `.... . .........._-...._.Expansion Attic ( ) Garbage Grinder ( )
per, Other—Type of Building ......' ................... No. of persons...-........-..._........._. Showers ( ) — Cafeteria_(__` )
Q' Other fixtures _..._..............
a ----..._./ --------
Design Flow.z...............C� 1—ons per person per day. Total daily flow..... "`�---------------U.---gallons.
W Septic Tank/—Liquid capacit���_..allons Length................ Width...._.____.... Dill
meter............_._ Depth......._...._.
x Disposal Trench—No. .................... Widths....... _{_Total engh—.----- - ..._ Total le�liing area-------..._.._-----Sq. ft.
Seepage Pit No..................... Diamete/�. _ Nept inlet--------------------- Total leachingCtrea---e --------sq. ft.
z Other Distribution box ( ) Dosing tank ( )
a Percolation Test Results Performed by.................................. .�__.-_-- Date_._-.._-............_._.__....-..._.__..
Test Pit No. 1----------------minutes per inch Depth of Test Pit.................. Depth to ground water................_.......
(_, Test Pit No. 2................minutes per inch Depth of Test Pit.............._..... Depth to ground water........._.........._...
J.
---------------------------------------------- -----------------------------_.....
DDescription of Soil----------------------------------------- - � .� -�.... ...... ------ -
------ --------------------------------------------
V --------------•---•--- ---...------------------------•----------••--.-- y��----••--------...._......-•------•-•-----------------._._.....------------------------•---------------------
W
------------- ----------------------------------------------------------------------------------------------------------------......---------------------------------------------------------------
V Nature of Repairs or Alterations—Answer when applicable...............................................................................................-
------------
Agreement:
The undersigned agrees to install the aforedesc'ribed 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' '
Signed.---'-----.�---- -------------•-•-•-----•--=-=----------'�-'---------------•• !-
C /�i I�", Date
Application Approved BY> �` r x .........,i�i�lJJ..: /_^ / Date
Application Disapproved for the following reasons---------------------------------f. .
..............•--------------•-------•-•---•------••-----------------
-•---'-••---•-----'•------•-------------------------••-----------------••----------•-•-----•-•------. -•----------..-..-......._-.....--•---...-•-----------•----------------------------------------
Date
PermitNo......................................................... Issued-----..................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OFF HEALTH
!...;1.�� 1........OF......../�; ;. ...(�- �--f/1 ..........................
if
Tntifirate of Q.Tkomplittrtre
THIS IS TOCERirIFY, That)the Individual`Sewage Disposal System constructed ( ) or Repaired ( )
b elf ----- .. r .--.. y`1--- 1 ,
�� �} //� �1` �-••�-Instaaier U ( , r_ /�
has been installed in accordance with the provisions of Article.XI.of/The State'Sanitary Code as described, in-the
application for Disposal Works Construction Permit No--------4.-qC: dated--------�.J.�b/... .7. -_.__.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST D AS A G RANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE---- ZI ------. --- Inspector.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF1HEALTH
..........-.... 't�?- '?.:,.........OF............:.: � ..t- .: ti----' ............
No.. / ---`---- (/ FEE-P....-----
Ri-rupoiial/lfoxbi (nutt�trttrtiut'i" rrmit
Permissionfiereby granted -------- ( .1.------- =----- .....---------......-•...................................•----
to Construct (r' ) or Repair,,,(j �,) ar�i Individual Sewage Disposal System
at No..'-�-J--(...------c"--------- '= =................
Street T
as shown on the application for Disposal Works Construction Permit No..... /_�__---- �ted_... �. �_ ._........
DATE ,! ....... ..... a.............................. - 7..........
Board of Health
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS