HomeMy WebLinkAbout0061 LAKEVIEW AVENUE - Health (2) l �A 1 -Io I ' L.i
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S M E A D
KEEPING YOU ORGANIZED
No. 12134
2-153LGN
LE MIN.RECYCLED
INULAM CONTENT 10%
Card affnmrscurcing POST-CONSUMER
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MADE IN USA
GET ORGANIZED AT SMEAD.COM
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Fmm....-:.2r.................. `� w•
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 0 HEALITP,
_....--- OF.............�,4�44 ..... a ...........
Appliratitttt for Bispn oal 19orkg (9ttttstrurtitttt Prrutit
Application is hereby made for a Permit &Constct ( ) or Repair ) an Iiidual Sewage Disposal
Syst at t
... �. 1...........
L on Addr s I f� ar�bt 1�p / !
... .�� <. a..................... ,Ifs'... � c�C! :: e
' wneY�. Address
Installer Address
U Type of Buildings Size Lot_-�_7f.: .Sq. feet
- Dwelling f=�No. of Bedrooms............._ ..._.............Expansion Attic ( ) G�fbage Grinder ( )
`4 Other—Type of Building ....................... No. of persons----------.:n�-.............. Showers Cafeteria
a' Other fixtures ......................................................
W Design Flow.......................::... _'gallons per person per day. Total daily flow.......... ' &------------
04 Septic Tank—Liquid capacity gallons Length................ Width---------------- Diameter................ Depth................
Disposal Trench— o.................... Width........ . Total Length.......... Total leaching area....... sq. ft.
Seepage Pit No.... .:.......... Diameter.44k*------/15epth below inlet....... ...... Total leaching area.... ft.
z Other Distribution box ( ) Dosing tank ( )
'-� Percolation Test Results Performed by...................:..................•-----------------------•-•--•...... Date........................................
Test Pit No. I.....Y'minutes per inch Depth of Test Pit.................... Depth to ground water._-__-____-__-_-_-_-.--.
(s, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water--._---__-_--___-----_-.
---- --
O Description of Soil........ w .......... _ ,���
U ..............................---------- -•--•............._..........-••-•-••----•----•-••-•.._...•-••---•---•--•-••-•.....-------••-•------•---••---••--•-•••••-••••----•-----•-••-•...........•-•--
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—The undersigned further.agrees not to place the system in
operation until a Certificate of Compliance has been isstie&b he board of heal
Sig "---- ---------
Application ==
llate�
Approved By----- �`-;• -- - IC-•-- •-•. -` -- t ...�. ,�". .
l
�..
Application Disapproved for the following re¢sons----------------------------------- --------- ------------ ......-----...•.._....---...............
................................... •��------------------------------------.......------........---------------........ -------- ------....--•----P-----•... .....--- -•
Date
Permit No..... ............................................... Issues �.... .Cs3
to
No....._-,-,,.------- FRim...............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF,)-IEAL _TH
, � ,t
Appliratinn for Disposal Works Tonstrnrtion thrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
S st at a
Y h
I o St n Addressa r or t No f r
�r '
. ..�
f ? _
{J 'f .s J �y�* a,�►o x..,•• .... t �� ......,.._.•...... .. t •, f � ��„�,�'�".wi;�: J..}}i! ,...✓3 .. =�' ��___�r`g�iYF{'�rrP
Owner _ Address v
r
� .............................................Installer.....,..............,._...,.,.,....,.... ...,....................................,..-Address ....__..__._._.._............._._....____.
Q Type of Building , Size Lot_.. __ __ _� - .Sq. feet
Dwelling_0' o. of Bedrooms................ }�....................
Attic ( ) (xai age Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
a Other fixtures
d - ----•----------•-----------------------------•--------•-•••---
Design Flow_______________ „iLSO.____gallons per person per day. Total daily flow.......... . ..........gallons.
WSeptic Tank—Liquid capacity,,�;;te"a':!gallons Length................ Width....... ........ Diameter................ Depth...............
x Disposal Trench— 0..................... Width..................___ Total Length......... Total leaching area....................sq. ft.
Seepage Pit No._.: ._..•.._.._ Diameter.,/ .; j,� 1�epth below inlet_._..__.._.._.. Total leaching area ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed bv........................................................................... Date........................................
,4 Test Pit No. 1.....,6. minutes per inch . Depth of rest Pit.................... Depth to ground water........................
Li, Test Pit No. 2.................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a -- ..
0 Description of Soil......... �,, � _.r * ;� x `r.
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—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued b the board of healt�
f �q
r^ Sig c _Y : . ,c' .s'rurt;e:, ,,: - -
!� �✓ ' f Date
A lication A roved B __. " r '; � r -,� ! { '" - ';.,
Date .
Application Disapproved for the following reasons--------------------------
..............................................t...................................
.......................:.....:.:..........••---•-----•••••---•-••--•-----......._•---••--_----••-••_..._.:.--•-••-••-•--••-•-•-------•---•-••-•--_....---•-••••...-----------•-----•....................
Date
Permit No.............:........................................... Issued.. ._�� ` ? .....................a
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH,,,
f-e!w7li ram?`?c............. v.........
(�rrtifirtttp �f �un��rfi��rr
THIS IS TO CERTIFY, That the dividual Sewage isposal S s em constructed ( ) or Repaired ( )
by..................................... _,_...----_•-• � �
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...................... " ___ dated....._._.�-_._�-.y-.� . .�____.__
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL NC ON �SA�!SF RY. `�DATE............... ...... ..•-- ............. Inspector.... ,r'C' � .;, ,....r..2.4 .,r r°l:`_. . ...........
THE COMMONWEALTH OF MASSACHUSETTS
� w . BOARD QF HEALT -1
..,- .. .#.. ,..._.,.d.;.._.......... OF.....,��N��i: �.'b•tr-•ic�-.1,..._.zs...e t::....�.�._s�................ �
No... ....1 ?...... FEE _,4 ..,::. :---
Dispnsa larks,T tnn �erntit
Permission is hereby granted..,,,, e.. ���..,�a.£! %�, � ......'w.. _- .... .........
to Construe or, Repair ( Vn tnclividual"'Sewage at
System,.f, ti•
�,l j l' ��..............
+v kY Street ..
as shown on the application for Disposal Works Construction�q,mit N r .. Dated.." `': ,.
.::� ..µ. ';.'-+rr.- -v•-- fir:.__w bsS;o rd -., s,
�
7.................................
a/ 'uf ElrtZ
DATE......_ -� ................. ........ ..
FORM 1255 HOSES & WARREN, INC.. PUi-7I_.ISHER$