HomeMy WebLinkAbout0049 CENTER STREET - Health 491,,CENTERAVENUE
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A-�- 327- 068
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
_. sY.�/.....:... ...-OF......
��!��
Allpftration for Disposal Works Tom4rnrtiun Fumit
Application is hereby made for a Permit to Construct ( ) or Repair (4-� an Individual Sewage Disposal
System r. at• 1/
� /�A191 Loc tt* t�ss• /� r L No.
h! s✓._. t1.a?x .f�' �t-------------------------------- C.�f4�1�_... a. /---•-
Owner ddress
aj? _ —-------------------------------------------- ------5
Installer ddress
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder
a`4 Other—Type of Building No. of persons............................ Showers
YP g ---------------------------- P ( ) — Cafeteria ( )
Otherfixtures ------------------------------------------------------•----•--•=-•-------------------._.....----••-----------------------•-•••-----------......_---••-
Desi F� ---------------------------------------gallons per person per day. Total daily flow............................................gallons.
1:4 c Tan —Liquid capacity b�4Ogallons Length-t'_ Diameter.......'------- Depth- —7 ........�
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........................................
,4 Test Pit No. I----------------minutes per inch Depth of Test Pit.................... Depth to ground water--_-_----____________--.
tz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a -•-•-----••--D--;!-----••-----•-------------------•-----------•-----------...----------- •----•................................................................
Description of Soil---- &t-Yokoc.....--•.._.dt.J J...-� _�;?1--------. �'. � .......
.
x
U --------•---•----...----•--•----------------•--••••-•--------•----------------------•.......-•--------•-----------------------------•----•----•--•--------•---------------------••...........-•---------
w
UNature f Repairs or Alterations—Answer when applicable..._._..,'� _Q_ _ ................................................................
......'°-krLf f'� ------J value= 1 e?r'h' � -----------------------------------------------------------------•-•---•--•---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
TT/'1s^
the provisions of Ll i IE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b e> issued b�the board of health.
Signe 1` - � � f 7
®® w� Date
Application Approved By............., yam_=J_.1 --%- -
Date
Application Disapproved for the following reasons:-----•---------•----------------------------•-----------------•---------------------------......---------••••...
...-----•••----•----••-------------------------------•----------•---•---.....-•-------......------------•--------------------------------------•----------•-------------•------------•-•--------•-------
Date
PermitNo........ r t1 L/------------------•-.. Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......10.WW................OF.........�'�,... �r..............................
(EntifirFa#r of TuntpliFanrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
bY................... •� r-------•Cic ct ........................ ----------•-•----------------------------•----•-----........._..------....._...------------------•-•--
Installer
at---------------4� '?------- ---------•------------•------------------------------------------------------------------
has been installed in accordance with the provisiol sTIT-ALE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No........ ... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector................................. ..........
1 Q
No.... '..A!-.Ll.y. FEB...7S..;"."'.-_-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
` _ .................OF..... IV�IAd lk
Appliratiun for Biupuii of Works Tonstrurtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair (`-j an Individual Sewage Disposal
System at:
Lodi
................................ r ?�o
��� �7...!7!A,e�`w"�!1 .9r�• fir, .
aas � Owner
�ddress
.1(nn wyo, ----=------......... -----v .Zv.....k.t
Installer
�F U 6 .
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.: ... ..................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures
W Desi � . _ _. _ __. _... gallons per person per day. Total daily flow...........................................gallons.
an —Liquid capacity/.a'`ZW.gallons Lengthl*.!4."Widths""6�"y Diameter_____" ...... Depth_.,'���
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 ( ) r
aPercolation Test Results Performed by..................................................................... '--- Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
t� --•--•------•--------------•---------•-•------•---•--------••-----•-------............--••--......-•.........................................................
0 Description of Soil--Xd O74'4...........IS' .- <<,Pqn cw..------
x
U
w
x ----------------- - --- ---
U Natur�f Repairs or Alterations—Answer when applicable--____-_/ ' :_ b____-_____-_•---_•............................................
. •L °1'd. c 1 '� s> .t l .....464'_4Rkw.....1 P ----------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T T L:: '
$ p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
9 operation until a Certificate of Compliance has bgeg issued by the board of health.
Signe�j -
--
Date
Application Approved By.............
Date
Application Disapproved for the following reasons--------------------------------------------------------•---•-------------------•--------------------------•---
...................................••---_.........."•----•----••----'-'-•----•'---.......--------'---•--••-----•-'------------•------------•------------•'-----------•'---••-•--------......-'•---'•'--
I Date
PermitNo.-------� .'--.� • _ ................ Issued.......................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....... .................OF. 3R.00lr .46.��`�.t4ae...............................
C9rdifirFatr of Touapfiatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( }
by...................�,Caxif_t*........�.ca ............._..
y� Installer
at............... -- _--•-�7- -------- - .........................................................
has been installed in accordance with the provisio s�i�C: 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.__....Z..? ..._�4*..v-__- dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
i\TO. 1..:.�S.S .................OF........ % �" r. ........._............... FEE.--.f•� .-•-
r
Disposal Vorkv Toatutrur#iun rrntii
Permission is hereby granted............C •-----�.ews�t�---------_----•..............................................................
to Construct ( ) or-Repair (>e an I dividual Sewage Disposal System
atNo.............. - -- -----------
Street Q►
as shown on the application for Disposal Works Construction Permit No?/.'.&7-p_-- Dated..........................................
•
.................................. + .................................................. ;
Board of Health
DATE............
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