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Home My WebLink About0211 PARK AVENUE - Health - - _ _ : 0 I r i ( i I i i 4 a i R` N K SSMEAD 0 KEEPING YOU ORGANIZED No. 12134 2-153LGN 0 SUMM amFOREM MW RECYCIID 04MAM CONTENTI CardeffibwSwrcbp POST.CONSUMER® www.iflprcpram arp sampo MADE IN USA GET ORGANIZED AT SMEAD.COM FEE. .................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................OF...... .....................I...I............................I.......................... \ \��- � Applirativit for Dispotial Workii Towitrurtion Punfit Application is hereby made for a Permit to Construct or Re air an Individual Sewage Disposal System at ..... .... 0'------------"_ Lot .......... ...... ----------------------- . ........................ o.cali%, d e AL or Lot'd . .. . . . ....... ...... ....... ......... ...*.......... ddres .......... ............ . ............... ............. .. .. .....!t...... ................................. 4i In aller Address Type of Buil 1 Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder ( 0-1 Other—Type of Building -----------_-------------_ No. of persons............................ Showers Cafeteria ( P4Other fixtures ..................................................................................................................................................... .Design Flow.....:......................................gallons per person per day. Total daily flow............................................gallons. W -P4 Septic Tank—Liquid capacity............gallons Length................ Width__-...______-_-_ Diameter..........._..._ Depth............_--. Disposal Trench—No. .................... Width.................... Total Length......__.__......... Total leaching area....................sq. f t. 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�-4 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.-____________-_______-. fi, Test Pit No. 2.......... ....mi Depth of Test Pit--....._..._._._:_.. Depth to ground water..._............._.._._. ....... . ......................................................................................................................... 0 Description of Soil..----.... .. ........................................................................................................................ U ----------------------------------------- ---- -------------- ---------- -----------------_----- -.--.-.-.-.-4-..- -.-.-...-....-..-..-..-........ ----- -- -- -- - .----.---. UNature of Repairs or at o —AnswnWhen applicable.._ - ., _- ----- ble- - ., ..... ...t... = . ....................................................................... ................................-..-..-.. -.- . 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 Aissb e bVrd of h71h. d . ... .•....... ....... . ................................ 'Jigne ..... D te ........ ---- -- --- -- Application Approved By......... ao ", .)d� .. — u 7...2 f6ee Application Disapproved for the following reasons:......................................7.............................................................. .................................................................................................................................................................I....................................... Date PermitNo......................................................... Issued...............................................0........ Date No 4 Fmc.04 .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF_................................... Applivativil for Uhay.aiial Worka Tout drurfivn VarAft Application is hereby made for a Permit to Construct ,( ) or Re air ) an Individual Sewage Disposal System at: �, , it .....,�yd �• "�. _ '' ........ ___�. .. '-/ I:ocatio ddress rm/ ..... ` �,,¢�,....... ........... ........ eddies .................................. In Iler 'A r UType of Bul xi ` Size Lot............................Sq. feet DwellingNo. of Bedrooms............::..............................Expansion-Attic ( ) Garbage Grinder ( ) Pk Other—' Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Pa 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 ( ) aPercolation Test Results Performed bv..........................=................................................ Date........................................ ,4 Test Pit No. 1....:...........ininutes per inch Depth of Test Pit.................... Depth to ground water-_--__--_--__-_-_-_-_--. Test Pit No. 2................minutes per incl Depth of Test Pit.................... Depth to ground water........................ . ...-•--=------------•--••--•--•--•-••-••......................................................... O Description of Soil --•-- - b ...- ....................................... ----------------------------------------------------------- --•--------------- ---•--------------------........-------••---•---------•------•---- ..-------- W ----------------------------------------------------------------- -------- txj Nature of Repairs or, V�tatior,—Answ�hh. pplicable. ..:..___ , r � ^._. .tl...._.. 2e, ------•----------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article x I of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issuad by the board of he th. Y D Application Approved BY '''" F;" fig, - r-'; t �,, Y-t' cr D ate Application Disapproved for the fallowing reasons:,---------------------------------------- -------.............................................................. ----•---------------------•-------------------------------------•--------•--------•--•-----------_.:._....----------------•-•----•---•---•------------------------------•----------•-----•-•------•-..... Date PermitNo.......................... ...... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OE HEALTH �- . 'e.° 't: Tr ifi,ra#r of Tom"I turn TICS j0 C - Tl y ha. Individual Sewage Disposal System constructed ( ) or Repaired ( ) f r �C ,r 1 ...T -- - ---------- ----- has been installed in accordance with the pr visions of Article XI of The State Sanitary Cod as described in the application for Disposal Works Construction Permit No----------------- - dated Z ' :_ �' ............. PP P 7 THE ISSUANCE OF.THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A G ARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...................................•--•-------------•••---•--------............. Inspector•..... ••--•• ....... THE OOMMONWEALTH',OF MASSACHUSETTS BOARD HEALTH , ' f No.... .. _.. FEE.d.�...... ......... r Permission is hereby granted ........... :_ ..................................... to Construct"( ) q} Rep 'r.( an Individu<#`._ wage ," sal System at No.,_-; 11i... , Street as shown on the application for Disposal Works Construction per`t No.:7 _ Dated �r Board of Health DATE•---t .... • ---- .................. .:............ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS -