HomeMy WebLinkAbout0030 ESTEY AVENUE - Health 3� Es+ �e . � Po'lannis
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M E A D
KEEPING YOU ORGANIZED
No. 12034
2-153LBE
SUSTAINABU: MIN.RECYCLED
FORESTRY
INITIATNE CONTENT 10°h
Certified Sourcing POST-CONSUMER
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GET ORGANIZED AT SMEAMOM
L O CAT IONS SEWAGE PERMIT NO.
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VILLAGE
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I III ST/�A LLER''S NAME i ADDRESS
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Lon �..C,fiia\ ix (e,
S U I L D E R OR OWNER
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED ���
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......Town.........OF...... �.���r�/1.�L� .�-�.........................
ai
Appliration for Uiovoottl Work, Tonotxnrtion Vamit
Application is hereby made for a Permit to Construct ( ) or Repair (y an Individual Sewage Disposal
System at:
.�.3.0.. /. .......�����' � .......................................................
•............... -•--•----•................
L ca on- ddress or Lot No.
:...._ . _l �........ ��e:............................................. �r.� �.s- ..............................................
Own ress
---.. R• ,J__/C.............................................
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons............................ Showers — Cafeteria
a 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..........._............................
aTest 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........................
..........
t
O Description of Soil...............
_.. - - - - - -- - ..
x
W --•------------------ .--------•--•----•-----•----._...----•-••---- ------------------------ ........................................
UNature of Repairs or Alterations—Answer when applicable.............�..:�U� .___..� ___ 1. ._._.___.__......__.
---------------------------------------------•-------------•-••----------•----------.....••--_-•--------........--••----••--••-----•----------•--------•-•------••-•---------•---------••-.....•--•--...
Agreement:
The undersigned agrees to install the aforedescribed. Individual Sewage Disposal System in accordance with
the provisions of iITLL 5 of the State Sanitary Code The undersigned further agrees not to place the system in
operation until a Certificate of Compliance s be issued by the bo rd of health.
ned_ .��... ..
Application Approved B t . .... . •. ... ...................................------•----•-- ......
PP PP Y-•-••- ---
ate
Application Disapproved r following reasons-------------=-••----•----------...........--------------------•---------------------------=-••-•------•--•••••-
--------•--------•••.......-----•--••--------------•----•---..__._..._...•---•------•._.....-------••---•--•--•------------••-•-•--•••----••--•-----•----•-•-•-------.
Date
PermitNo........................................................ Issued........................................................
Date
j M
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/.. _I' .. ......OF.. ...: j° �' !r�*^? ..ter �. 1[�' �
Jkly irttiion for Diivniittl Workri TontimArtinu Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair (" an Individual Sewage Disposal
.System at: �.,. .,
�.al ................ ........................ .----...............••....................
... ..
LocaOT Address orb of No.
f
a OwneY f A ress
........... � _s{ )7e.......•.....................................
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' 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........................................
aTest Pit No. l................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........................
- -}------•----�,:;--;--.----y------
----------------
O Description of Soil._... �c�` ' ` `{ ......`.I.Z I c'•--- -----------•----•-••--•-•.
U ..........................-•-----••-••-••...---••---•••--•••-••.........................•----•-•.........---••••-•-•--------••••--•--•••----...............-•---•.
W ----------------------------------------•--------- ----------------------------------------------------------------------------------------------------- ---------•------ ------ ---------•-
U Nature of Repairs or Alterations—Answer when applicable.............�." f � ..._..
U P PP �- - PV ................
-------------------------------------------------------------------------------------------------------------------------------------••-----....----------•---------.......•••-•-•---•-••-•-••-•----•••-
Agreement:
The undersigned agrees to install the aforedescribed. Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be¢f► issued by the bo rd of health.ed
,9
c� r
�Iathe ,
f t`
Application A roved B :..:. ------
PP PP Y = - -- fj`•• aApplic
Disapproved f ' t following ea-sons:...............................................................................................••--••-•--......
............................................... .....................................................................................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
J. A
:.........e2. .r.........
Trr#if iratr of (Soutpliatur
THIS IA TO CERTIFY, !That the Individual_. ,!ewage Disposal System constructed or Repaired (G by.............: . '✓ f7.�..� e. --•--••------•--•^-•----•-•---......-•-•--............... �r
•e 1�d• p� !� 7 e � +� �"�f��Installer � t> .•/ �
at.._............ ----1 ; . r'�cfi = ' ° x �d � ...� .................................................. L ..: 1-..-....
-----y
has been installed In accordance with the provisions of TITIF 5 of The State Sanitary Code s desc ' ed in the
application'forl7isposal Works Construction Permit No._ ._.._,.. dated_.. , -.----•.------.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT:EE CONST AS A G ARA TEE THAT THE
SYSTEM W114 F CTION SATISFACTORY.
DATE._..1/... .._?-----
- - Inspe _.. . _...----••........................•-•------•--......•.....--•--•--••••......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD �,Q,F HEALTH
r ell
��,,rr
...r ........OF.......y - rt� at�e /. ...................... 1
No '"l�f i�-- FEE.....
• �i��r�a�.tl ur �uuu�rttt#iuu
Permission is herebyranted..._ ;3:_.. ...fts'`�,✓{�r� /
g + =�!e'r...._�. ......................•...
to Construe( ) Qx.Repatr ( ap%Individual Se.�a;e Disposal System I
at [ / J
1 _ ", _
1 Street
as shown on the applicati n for:Disposal Works Construction Permit No...... ._ ......... Dated Dated..........................................
..........................
...
and-of Health
DATE.. a ---•------------------------•----------
FORM 1255- A. M. SULKIN; INC., BOSTON »-