HomeMy WebLinkAbout0019 LAKE ELIZABETH DRIVE - Health aa� �t� a
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No. 4210 1/3 RED
77
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
..c...r+..`........
i
Applira#inn for Ui4pnsal Works Toustrnrtion Frrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
... 9. Oef
. ..........-2 1 ...........`.... •-•---.........!`W................ ----............----•---.......CC.C.l! .O..-- ...............................
Location-A4 dress . or Lot No.
... - 5 �1.....f---_�- ei Ica....................... .........--
Ducner Address
...............................
Installer Address
d Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms_.__•_.Z..................Expansion Attic ( ) Garbage Grinder ( )
Other—Type e of Building No. of persons............................ Showers
r� YP g -•------•----•-•------------ P ( ) — Cafeteria
as Other fixtures ..........................................
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
W Septic Tank—Liquid*capacity............gallons Length................ Width................ Diameter................ Depth................
x 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---------------------------------------
a 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....................................................................................................................................................................
x
U •••---••-•-•--•••--•---•-•-•••••---•................•-•---•----•-•...-••••-•••-•••--•••---•--••--•....•-•-••-•--•-•-••-••-••-•-•••••---•---•••••......•--•--•-•----••••-•.......-----••----•--------•-
W •----------•--------------------•-....------•-----.._..--------•--•=-•--•--------------------------------A------------ .......--•------ ------------------
' •-----------
U Nature of Repairs or Alterations—Answer when applicable____ .. - +.-- -r'.........................................�'� ��
0� ®
------------------- - --- -----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TTL:; 5 of the State Sanitary ode— undersigned furt!l r agrees not to place the system in
operation until a Certificate of Compliance has be ue y he boar of hea h.
Signed--•••-•...... . . .... .. � ..._
ae /
ApplicationApproved By........................................ ..... .... _..... ...................
Date
Application Disapproved for the following reasons-------------------------------------•--------•----------------•-----------------------------.-------••-••--
.........••---••--••-•----•.........--•-....-•---•••-••--•-----••--••........••--•--•...-•--•••---•-•••--•-----•----•-•--•-•••••••--••••-••--•--•-••••--:-•-•--••--•••--••--•-•••• ••••--•-•--••-••----
L-/ Date
-•
Permit No. ��...............`�--------------•--. Issued_............. ..........' %..........
Date
r
,..r
N / . ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH ,
�':.....-... --..........0F.............` 'A..
Appliration for Diopoii al Works Tomtratrtion rantit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
... v i �-
- Location_Address or Lot No.
,.-owner Address
Installer Address
dType of Building Size Lot.........___________________Sq. feet
Dwelling—No. of Bedrooms............................................................ "...................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
0.' 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.................... 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........................................
a
Test Pit No. 1................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........................
9 •--•••--•-----••--•---------•--•"-•-•-----•------•---•.........................•----••-.._.......••........................................................
0 Description of Soil.........
..........•--...-•------------------------•--.......-•--------------...----------------•-------------------•--------------------•--....-•------•-•-•-----------
V --•----•--•-•-----------•••'---'-...........•-•.......---•'-•------------------------•-......••-•-------•-•----'------•-._...-•---•-•----•--•-•---------••'-------•••-•......--------------•------•---
W ------------------------------------------------•---------------------------------- .......-----•--------- -------------- ------
!T! f'---------------•�
U Nature of Repairs or Alterations—Answer when applicable...:.�-�..k��._ ..__?�........:......................................................L'i .... ... .�'i---------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'TIE
.: .:.l•. of the State Sanitary ode e'undersigned furtl;er agrees not to place the system in
operation until a Certificate of Compliance has be n I sue y%the boar of hea h.f
.Signed :�.�?%'vt,---"----•..--- 5 .....•-- — -
.
e
_....��-�...
Application Approved B -�""-"
PP PP By................
..--•-•-----•- - Date�=--'•--'--
Application Disapproved for the following reasons---------------••--......--------------------------------•-----•-----'------•---•---------------------....._..._
..--------•----------------•-•-•--•------••--------•---.......---•----••-------------•----....----------•.................--------•-•------------------•--•-----•--•-•------------------------------•••--
Date
Permit No. :_='_...... ......................_ Issued_................
r _ ........
Date
`r
. THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.... .... ...:`...'................OF....... t;_-............-....rN. T.?...........z:...`.................
1
Tnrtif iratr of Toutphattrr
THIS IS
.---..TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by ........................{ e":.i.!^ ...--------......-----•------------•-•-•-•--..........-•----------•---•------•--•-----.. .................----.....--•------------------
Installer
at------.....= �..�..................�....................rC L� ! 2
has been installed in accordance with the provisions of TITrtZ''., 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No-------- -------- ... dated_...._-_._.I- .7._t_:_' ......
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARA TEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......................I..��............------.....------...... Inspector....................2 ----- _1......................
THE COMMONWEALTH OF MASSACHUSETTS itr�` t �!<< t U
BOARD OF HEALTH
if... I!ir;...OF...... '.l:.... . ..'':.t:.:...................` -
NO..... ........�� FEE...... ..... ......
Diopo,s.. ... rko tono#rudion anti#
Permission is hereby granted............................... ::
to Construct ( ) or Repair (. ) an Individual Sewage Disposal System
:.
Street
as shown on the application for Disposal Works Construction P�,zn>t—.No _"r j(nDated_._.�f__ ---
---- -----..'?...............
7 w Board of Health``
DATE...........7.1 �� ,! .. _
rf x ..........
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS