HomeMy WebLinkAbout0154 ESTEY AVENUE - Health P'/51 6*1 4ve ., &fkv; Ic
Ser. / Hs
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U'gaCATI0N SEWAGE PEILM�TvN0.
VILLAGE
INSTALLER'S NAME & ADDRE
B U'PL D E R OR OWNER
DATE PERMIT ISSUED �ey
DATE COMPLIANCE ISSUED
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No.._ .. ..... Faa. .................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD PF HEALTH
� .--.....OF..... .... ......
ApVtirtttioo -for Riipoiitt1 Workii Tomtrortioo Prruid
Application is hereby`made for a Permit to Construct ( ) or Repair (&< an Individual Sewage Disposal
System at:
..............................................st .--------'-----------------------------.---.--
Lo tion-Address
�o,�e�0� rr rt .......... �,fT . i9ve ��h��s
-•-•or Lot
o----o..
7 yy Owner) ,y Address �/
a VO� /� i SO J/�/ /h a`/ ST [/(f
.................'----.-•.....)....... * Q ----•- ...................................
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 ( )
Q' Other fixtures ---------------------------------
W Design Flow............................................gallons per person per day. Total daily flow-----------------------------------------.---gallons.
USeptic Tank—Liquid capacity------------gallons Length---------------- Width................ Diameter---------------- Depth------------
xDisposal Trench—No..................... Width-------------------- Total Length-------------------- Total leaching area..-..__...__._.__-__sq. ft.
Seepage Pit No_____________________ Diameter-------------------- Depth below inlet_-_________..__----- Total leaching areal-._-_____._.-___sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by--------------------------------------------------------------------'-'--' Date----------------------------------.-----
,� Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water.........-.--..__..__..
f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
9 •---------•----- - '
0 Description of Soil................s�_h_._...a�.
U --•--------------------------••------ ---'-----___----.----•-----.---•----'- ------- _ ------::_::_::-- ::__------_:___:._--
x ----------------------- ----------•- -.. A -�- ;-
V Nature of Repairs or Alterations,—Answer when applicable..._/' � �. _.... ':X! ---- Ge-soo._
-
--------------•---
- --------.-..-•
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 is wed by the board of bealth.
Si e - �- ---------------------------
Date7
.... ...................'__---____-__-___-_-___-_________-_____-_-___-_---__
Application Approved By ..... •--- ---- •. . -• =-- --- --------•---- ---- ----�/ " .`1_.- _
Date
Application Disapproved for the following reasons------------------------------ ----------------------------------------------------------------------------------
------------•-•-•--'-----'-----------------------•-••-------------------------------..................................... ------------------------------------------------------------------------------
Date
PermitNo......................................................... Issued........................................................
Date
No. .....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD QF HEALTH
�. .. . �`"�'t._..... ....................................... ........
Appliration -fur M_qpviial Workii Cnowitrurtion Vrrmit
Application is hereby'made for a Permit to Construct ( ) or Repair (t-I an Individual Sewage Disposal
System at:
Lotion•Address ye y or Lot No.
�!'EJ� ._.f.''s.Yt/h f SYr�# �1+1 ' RDie w.o 4-------------------
Owner Address Ir
w aj .4_.�A.1_f..................................... • ,/-w�6' ��"' " *.51-----•-6 _, wrr�3�;0-------------
--------- -----
"' Installer Address
UType of Building , `� Size Lot............................Sq. feet
�-, Dwelling—No. of.,Bedrooms..........................-- Attic ( ) Garbage Grinder ( )
Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures -•------------ ......`'----------------------------------- .................... ----------•-----------------------------------------------•----------
w Design Flow...,.,........................................gallons per person per day. Total daily flow............................................gallons.
P4 Septic Tank—Liquid capacity------------gallons Length................ Width................ Diameter----------.----- Depth_____--__...-_-
w Disposal Trench—No. .................... Width---------------.---- Total Length----__.---..____--.- Total leaching area-.--..-.___-_--_--sq. ft.
x
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..--_--_---------sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed b --------------------------------------------------------- Date--------------__-.-_-.--___-_-----.--.
Test Pit No. 1----------------minutes per inch Depth of Test Pit..------------------ Depth to ground water...-_-._.-.---.--.-_---
L14 Test Pit No. 2•_______________minutes per inch Depth of 'Pest Pit-------------------- Depth to ground water------------------------
---------------------------------------------------------------------------
x Description of Soil ----------
U --------------------------- ------ ....... ................................ _*------------ ------- --------- ........................................................
UNature of Repairs or Alterations—Answer when applicable ,!'�__._�c-0----.-tit a4-s-of.,.N G t S ml
1'A..... Via?t� �� 3:�'�`6 X_Af......*--- �a�c .. .��t� ----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 b is ed by the board of beiilth.
_
:77
1
-,� -e Date �+
Application Approved BY------ -S. r' ... � _.... .Darr
Application Disapproved for the following reasons:................. ............ ---------------------------------------------- .--•-------•------------------
Date
PermitNo.......................................................... Issued........................................................
Date
Lr
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
/.401 i .........OF....... - .. . .. ......w.........................................-
Tr tifira#r of f IOntli iarcrr
TH IS W CERTI Th Individual Sewage Disposal System constructed or Repaired
by ------•---------------------------•-. -------•-----------•--•---------
---- ..
Ins ler
has been installed in accordance with the provisions of A e XI of The State Sanitary Code as described �t jthe
application for Disposal Works Construction Permit No _ :_._.,�_-r`....._.. dated ..__y"_ _ _.�.----->,t1.......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM'. WILL FUNCTION SATISFACTORY.
DATE--- Inspector . ......................................
THE COMMONWEALTHOF MASSACHUSETTS
BOARD F HEALTH
..�....� .......OF :.. . .... . .......... .....:..... ..................... '".
No.. . ... .... FEE- .................
t �i����tt k,� n •-�� 4 r�i�tt rr�ti#
Permission is hereby gr to fr. `
to;Constru or R ( an. l
ndivi u+l Sewa Di oral Sys
f ., --w �s -y
Street �
as shown on the application for Disposal Works Construction ,, -_ ________-_ Dated_..
---••-- .............
+ DATE --------------------- --------- Board of Heat /
h
FORM 1255 HOBBS'.&WARREN. INC.. PUBLISHERS ,1/ zR...
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