HomeMy WebLinkAbout0039 EMERSON WAY - Health (2) 39 Frne�san Way
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rt THE COMMONWEALTH OF MASSACHUSETTS Q W Cs- '�" �� a d
BOARD,.,.( HEALTH
70r:1H.....................OF.........
Applirati.an for Rapnsat Worko Tonstrnrtiun Pumit
Application is hereb,}' made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: ��� 3
G� .�yE�sow l�d9 CE�P�.r v 4� s .....................
Location-Addr / or Lot No.
oA e . ..... '.P�.-� C / -1
- fT ��r --- -.l�T__....-----•----------f a ............-�� w
Own --------------------------------------•--•--Address
Installer Address
QType of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms........... ................. .Expansion Attic ( ) Garbage Grinder ( )
PA Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Othe�rs fixtures -•________________•-_•--_-_-_____
W Design Flow.......... .....................gallons per person per day. Total daily flow--------3Q-4-----------------------gallons.
WSeptic Tank—Liquid capacity./Q.694gallons Length................ Width---------------- Diameter................ Depth................
x Disposal Trench—No. Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No...144,0f) iameter...-............... Depth below inlet.................... Total leaching area__3Q1�... ft.
Z - Other Distribution box ( ) Dosing tank ( )
a Percolation Test Results Performed by-------------------------------------------------------------------------- Date--------------A_�
--- --•- ..
a Test Pit No. 1—.............minutes per inch Depth of Test Pit.................... Depth to ground wate __-___ _-.
tz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... De oun
................................. --------------- ----- --•----- '
ODescription of Soil................................. --•--•- . ----•-•...... ...---•---•-•---••--•-•-•-----------•---------------------- ------------------
sh
U
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 XI of the state Sanitary Code Th undersigned urther agre not to place the system in
operation until a Certificate of Compliance has been iss a boar4oealth.
Signed .1!
Date
Application Approved By----- �•••---•---•- --••---•---•-----•-----•-•-•••-•••-----••------
Date
Application Disapproved for the following reason :....................
--------•-------•--•--------•......................................... ---•----------
---•-•--------------•---------•------•--•---•--•---•--------------•-----------------.....--••••----•---•-
Date
Permit No.....3'0....................................... Issued.----- - 7-�Z/............
THE COMMONWEALTH OF MASSACHUSETTS
E®At�®,®E HEALTH
is-,�'.�+ibe";p ,s....-. ........- OF. -
Appl ralioat for Disposal Works Tattitrurfivtt Prrutit
Application is Hereby. made for a Permit.to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.� ... ................ . ...... ................. - ---------------------. -
Location-Address ��'. or Lot No.
.............................. ...................................... ................ L O/li 9
Owner Address
W
Installer Address
UType of Building Size Lot............................Sq. feet
`-, Dwelling—No. of Bedrooms------------- .............................Expansion Attic ( ) Garbage Grinder ( )
� Other—Type of Building.' g ............................ No. of persons............................ Showers ( )-.-.Cafeteria-(-----)-
d Other fixtures --------------------------------- -----------------------
--------------------------------- -------------------
W Design Flow.._.___,:s'_I............................gallons per person per day. Total daily flow________ �"'..0........................gallons.
WSeptic Tank—Liquid capacity-�!j_4k ftallons Length_............. Width-_______....___ Diameter---------------- Depth.---__-_.__---
x Disposal Trench—No.................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No Dameter _________________ Depth below inlet.................... Total leaching area...._: 4 .sq• tt.
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._.________-__________--
(� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water____________________-.-.
0 Description of Soil................................................
.
c� ------------- - --------•----------------------•----------
W
VNature 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—Th undersignedF�urther agre s not to'place the system in
operation until a Certificate of Compliance"has been iss> db he board of�li'ealth.
r¢
Signed.... ---- --------------------------------
Date
Application Approved By.•._._____.-_--
Date
Application Disapproved for the following reasonsP*___ •---- ,. Iliad'!.......................................
------•-------------------•-----------------------------------------------•--------------•--------------•-----•-•---•-•••••-------••-••------•-•----------------•-----------------•--••t'--------------
IE?ate
Permit No. I Issue-----------•-----------------•....--- . ...--°--------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.. s.................OF......... 9fir. ., ' .f ..............................
T Prtif iratr of TI-Intlrf attrP
PRVS IS(L O CE �IFY, at the Individ Sewage Disposal System constructed ( ) or Repaired ( )
• In taller ..�
at. - •-f'�y 1_-h_ 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..... 5_ ___ _____________________ dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
f r ... ✓. .... �A'
DATE................................................................................ Inspector.•--'-"•--===•---------..........................................�
-.--.........------•
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No.......... •--- FEE........................
�r i,�����tf � aa�•k� Cnlatt��rt%r�i�tt PrYtti�
Permissionis hereby granted........................................................................------------......•-•---------••-----•----......---•--•----••----•-----
to Construct ( ,<,) or Repair ( ') an Individual Sewage Disposal System
at No--------•= -t- t" ._ _.. K t
== ° -.-
Street ••
as shown on the application for Disposal Works Construction Permit No._ _�.. -
_.. Dated --- .....'.
DATE----------------------------- :-------------------------------------._..._:t
•Board of Health e
FORM 1255 HOBBS & WARREN, INC.- PUBLISHERS