HomeMy WebLinkAbout0052 MAPLE AVENUE - Health (2) 0 3s i
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N S M EAD
KEEPING YOU ORGANIZED
No. 12134
2-153LGN
MIN.RECYCLED
INITIATIVE CONTENT10%
CertiHeffiberScurefng POST-CONSUMERS
wwwAgrogrem.orp
5i101Z90
MADE IN USA
GET ORGANIZED AT SMEAD.COM
No. q F$s... .......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........OF................ iSlGC
Apphratiou for Bhiposal Morkii Tonstrur#iun Prrmif
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
�'` — ���G�
....-••-•---
. �U .....•---•........�[ 1�r71O>G C -•-•-•--•...................•--..._..
_---.... C.
Location-Address, •••or Lot No.
................ ,a..... . �J��l�.ScIR/................ .._.........................•....... .......-•-•--....._._.....................---
L< _ •Owner Address
.a ........... C.S.............. 4x..40t..4....................................•..... ..............................................----.......------..._...---•-••--••-•---•-•-••--•--
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures _________________________________ _
Design Flow___._____..3,0..........................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width--_----------- Diameter................ Depth................
x Disposal Tre ch—No.____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
5 Seepage Pit o.___---/_eFD0... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
4, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
P4 ............-................................................................................................................................................
0 Description of Soil..........................................
...........
•-------------------------------------------------------------•---------------------------------------------------
U
W
----- ........... ............................................. .....................................................
U Nature 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 by the board of health.
Signed_._ --.__ GS.:. �_ A.e_�................................... /�:_I'_-7 �...
Date
Application Approved By- ....... = -- •- - - ---------------------------------------------------
Date
Application Disapproved f the following reaso s:-
-----------------------------------------------------------•-•------------------•---•--....---------------••-•-•-••-••••-•••---•--•-..._.-..._.-------•--------------------...•-•••••--•-••---••-..._..
Date
Permit No......y__-_ Issued..__._�� __�" 7-2--
1............................. .................................
Date
No......... t FEE..: .::{ . 1.........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
, ,
:• pplir Lion fur �H mial Worho Toniftru.rtion Vrrmit
Application is hereby.made for a .Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
............._....F........ ._....... ................. ...............••........... - ..:...../ ----------
Location-Address, or Lot No.
! C: ..........,'t,{ .. � ...'. ......... ......••••.................••..
Owner Address
.:.:............. ......:......_.................._...................
Installer Address
UType of Building _ Size. Lot............::.:...........Sq. feet
>, Dwelling_No. of Bedrooms.......... ................................Expansion Attic ( ) Garbage Grinder ( }
aOther—Type of Building ..........:................. No. of persons............................ Showers ( ) Cafeteria ( )
a Other fixtures. -------------................................d
W Design Flow..:........i.1.................---------gallons per person per day. Total daily flow--------------------------------------------
r4 Septic Tank' Liquid capacity............gallons Length...:............ Width...:........... Diameter................ Depth................
Disposal Trench-- No.. ..........._ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit` flf Z440',t Diameter.................... Depth below inlet.................... Total leaching area............7.......sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results. Performed by ......••••-••-••-••--•••-•---•--••----•-•••--•-••......• Date........................................
Test Pit No...1................mintites per inch Depth of Test Pit.................... Depth .to ground water.--.__--.-__-_____------
fi Test Pit No. 2....:.:::.......minutes per inch Depth of Test Pit.................... Depth to ground water...-_.__.__..__..__----.
Gy
O Description of Soil
Y t
----------------- ---- ...................................__..._........... •........._. ..............................................................
U Nature of Repairs or Alterations—Answer when applicable...........................
..-•........................................................
r �� ` = 'y... ' C• 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.
Signed3: .:.. ........................................ ...............................
.> Date
Application Approved BY--`; :': _ .}' ............ ........................................
Date
Application Disapproved f d'/the following reaso -------------------------=-----------------------------------------------------•------------------------.......
----------------------------••---••-•----------------...--------•--------••-----------•------•------•---.•••-•-•----•-•-•-•-•---•-•••---•--------•------•---•--------•---•-----•--•••••---••-•-••-......
Date
Permit No......'2 °. `.............. .................. Issued-------'' --
Date
r.
"THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
- Al
F � 1 Al
f�rrtifirate of To pffiturr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by................... .:.=-� .........................`
Installer aa
,5 .4k. . R 7 / 1 e Z ..... .. ,.'_................................
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 Pert-nit No------- .. .................... dated....../1-Y. .....
, ,,.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
_DATE f.`: ................ Inspector.....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH .
........... :...✓ .....................OF
No........ =°° f... FEE.........................
Permission is hereby granted........ = .--•-` ......-- ----•-------------------•-•-...................................................--
to Construct or Repair ( ) an Individual Sewage Disposal System
atNo..._.....z .;e': . / �.�; �r ..............-•--••-- ...... . ...............••------...---•- •--•--... .......... ...--
Street
as shown on the application for'Disposal Works Construction, Permit;No.....°:_ 0._. Dated__.__`..t'�:
s.
10 Board of -Icalth
DATE---- "'" -
�. /
f:f._..-------"---1----� ----------------.......-..................
FOR?4 1255 HOBBS & WARREN. INC.. PU6LISHERS