HomeMy WebLinkAbout0051 EMERSON WAY - Health (2) 3'l �i�Ierson Wa� Cw�+ ,
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
.- OF......_...................................... ..... ---------------------
Appliration -for Dii niitt1 Workii Tom5trurtton Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair (vf an Individual Sewage Disposal
System at:
-•-- -------- - -------- -------•--- .................cam----------- ---•-•-----------•--
- Location-Address -- or Lot No.
............. ----------------------------•------------------
��++,�, Owner Address
Installer Address
QType of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms_---_nR--------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures ---------------------------------
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
W Septic Tank—Liquid capacitvl allons Length................ Width................ Diameter---------------- Depth---.. ..........
Disposal Trench—No._-__f. Width._AO Width. AO.___-_--- Total Length-__,3-Q_.1------ Total leaching area... ....sq. ft.
Seepage Pit No---_---------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. it.
z Other Distribution box (1.) I Dosing tank ( )
Percolation Test Results Performed by.------------------------------------------------------------------------- Date---------------------------------------
,� Test Pit No. 1..._------------minutes per inch Depth of 'Pest Pit.................... Depth to ground water.-.-.-. ----..--.-.--..
Test Pit No. 2....._----------minutes per inch Depth of Test Pit.................... Depth to ground water._._.---__--_---___-__
------------- ------- ------------•-------------•-----------------------•------•------------------------...------------•-------••--------------------
0 Description of Soil-----. ...... ----�� 1 .-------------------------------------------------------------------------------------------
V ---- ----------------- ----��`--
x ------------------------------------ Y : ::: . -•._.. ::::::. ::: :::.
V Na re of Repairs or Altera ons—Answer he applicable._.____• _._.....-. _______ __ _ ______ ..-..___......_......
.4--o-- -- -- ----------------------------------------------------------------------.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article YI 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 g health.
Signed.. .--- ---- ------- , � :31
` j Date
ApplicationApproved By-------------------------------:..................................................................
Date
Application Disapproved for the following reasons:................................................................................................................
------------------------------------------------------ --------------------------------•-------------------------------------------------------------- -----------------------
Date.......Permit No.---------•--------•------------------------------------- Issued.--- �
Date
No.--- ........ FE$.........'....I................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
t. °. t..--•• ........OF. *. �° �,
..... ....... . '. ....... ....... ..... .---.... -..:._..._.-....-..-----------
Applira#ion -for i,i uiitt1 Workii Tons#rur#ion .erunt"
Applicatf ion is hereby made for a Permit to Construct ( ) or Repair O an Individual Sewage Disposal
System at,,
�,✓ Location-Address rf` or Lot No.
.v.....,,.f °
Owner "I Address
W !. t . - -'r", - , a . , .. C a Wiz=-'=-" s r � _
--------------------------- --- ---- ---------------------------------- ••--------------------•--•--
Installer Address
Q Type of Building Size Lot----------------------------Sq. feet
U Dwelling—No. of Bedrooms------ ________________________________Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ___________________________ No. of persons---._-____.____-__________ Showers ( ) — Cafeteria ( )
0.i Other fixtures
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___-j"_________ Total Length__________________. Total leaching area--- -_4" ------sq. ft.
Seepage Pit No-------------------_ Diameter.................... Depth below inlet.................... Total leaching area---------------___sq. ft.
Z Other Distribution box Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date----------------------------------------
0-1 Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water-�____-.___-__-__-_-_-.
(t4 Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water-_-_-__________-____-__-
. P+ -----------------------------------------••-----------•---------------------------------------
Description of Soil----------------
--- = = "'=
U ----------------•-•---••--•---------------------------•------------------------•-----------.............................................................•--------------------------•--•• •------------
W
- --- ---- -----------------------------------------------------
V Nature of Repairs or Alterations—Answer when applicable._- --.w ' - r
--
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.
Signed--::...... .....................................-
Date r
ApplicationApproved By........................... .................................................................... -------------------_---
Date
Application Disapproved for the following reasons:----•------------------••--•---•.-------•-------__..._..-----------•-••--•------•---•----------•-----------•----
------------------------------•.----:-..-.••..--.-------------------._....--•----------•-------•--------•..---------•---•--------------•------------•----•----•--•-----------_._..._...---•--------------
Date
PermitNo......................................................... Issued........................................................
Date
...^ant
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..............°.. .......�_............OF. ° . . ........................
Trdifiratr Ai- Tomptianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( --)
If
by
. -' j: '6
F Installerat
s t,
{ !r- s, r_..-'---------------'...--------------------------•---.•......._..........--------------
has been installed in accordance with the provisions of Article XI of The State Sg nitary Code as described in the
application for Disposal Works Construction Permit No_________________________________________ dated.______. ___,_ %_.a�_.__
ti ____________ _
THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONST UED AS A GUARANTEE THAT THE
SYSTEM WIL FUNCTION SATISFACTORY.
DATE--------- •---•----------------•-----•-------------•-•-------•------------- Inspector--- --- C
i
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTW
.......................................... <_ fe.
OF.......-:-....-.:-
rJ
No..... ./1__._-_ FEE........................
Permission is hereby granted____________________________________ ___..-:::=_
to Construct ( ) or Repair (°.%) an Individual Sewage-Disposal System_
at No. ,_ .-i -- = `"-==-- -------------------------------------------------------------•----- nn
tom'
Street
as shown on the application for Disposal Works Construction P t No________ _ ____ __ Dated._.._.::__...__..__-.______.__.__'._____
_-__•__•_• _ __ •___ .......
_- ........... -'IC --•- --------------------
rd --
S/ � Boa f Health "
DATE••-_.7 f F ...............................
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FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS /
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