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HomeMy WebLinkAbout0167 STEVENS STREET - Health AP17 34tvms S+.) 44M�if 304 loaq 7 W Fo LOCATION SEWAGE PERMIT NO. S11 VILLAGE 4LIllwXy I N S T A LLER'S NAME i ADDRESS e U I L D E R OR WNER DA T E PERMIT ISSUED DATE COMPLIANCE ISSUED C © �8 � o a � � Q ............ THE COMMONWEALTH.OF MASSACHUSETTS BOAR® OF HEAL H -•----..........1..P4. wn...OF......Saw,5Pa, . Appliration for Uhipoii al Works Tomitrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair (,/) an Individual Sewage .Disposal System at: •••- Address or Lot No. ........ f i_12.Y�.1..�. E1. . ............................... &.jZ ..................................... .f:1. 1.Is-------------•-------....._.........----..........--- Owner y_�,�, — A ess Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of ersons____________________________ Showers a Other—Type g ------•-•-•----------------- -------P---- - ( ) -- Cafeteria.(..._�.. Otherfixtures -----•--------------- --------------•-••- • -•••-••---------•------------•----•----------.....----- 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........................................ W Test Pit No. 1................minutes per inch Depth of Test Pit_....._______..._... Depth to ground water........................ fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ W O Description of Soil.......... - - -- - - - - "W V --•-----•---•..................................•----••--•-••--••---._...-•--•••••-•-----------------------•---------•••-•--••-•---•--•-•---••...-••-•--...•--••-----......__...•---...--••--••---••-•--- W x ----•---••--------------------------- -•--••-•--------•-----------------••---•-••-•-•-••••-•---•---•-----------••---•-----•----...--•----- V Nature of Repairs or Alterations—Answer when applicable.___._J__=1,�Q�Q______ . .�__._.'-._.. . __- � ___.. -- --- -----------------------------------------........................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIIL U 5 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 G; k.—A......... ---• M �" '� , �� .. te By.......... __Lvl� 12 D to Application Disapproved for the following reasons__________________________________________________________________ SIC Date PermitNo......................................................... Issued. ------•-•---- Date f y ! , ''tea hI No......... ..... FEs.......: :.............`.... THE COMMONWEALTH OF MASSACHUSETTS - BOARD -OF HEALTH ..........................OF.....11f{3;:J = ......................................••-..........._..-•••-- ApptirFation for Uhipvii al Works (fonvaratrtion Vamit Application is hereby made for a Permit to Construct ( ) or Repair ()/) an Individual Sewage Disposal System at: Location-Address j or Lot No. ........ .....................Owner..... C...._.....• -,i --•-•-- ---f-- ...........Address'**---------------------------------------- ........................... ................................................. Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) `4 Other-7ype of Building No. of persons____________________________ Showers — Cafeteria 11.1 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.J_................... 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-----•-------•••••--•-............. - Test Pit No.' 1________________minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Pd ,-ti fa_________________ -------------------------------------------------•-•-•----_____------•-•-------__________-------•---- O Description of Soil.......... -% � : T )t / t.,� x - -------•- ----•-•-•--•-••-•-••-----------------------------------------•-----•------------------...•-----------••--•------------- V -------------------------------------------- ••-••-------------- --------......••••-•--------------------------------------- ................................ •----•-••-----------•-••--•----------•••-•-•-•---•••--••.`----•-••=---------•---------------••---••---•---•-••••••...•••-•••....--•---•------•••...__.._._._.__...----•.....__._...._._....•-•- U Nature of Repairs or Alterations—Answer when applicable____._:_.. __..._'_..___..!:....!.C.!_____________... __.._. __._._............... --------------•--------------------••-•-...•-•--••••-••• --•-•----•::--------------..............------•----••-----------------------••----•--•---•-----•••--•-••-••••••••-r , Agreement: The undersigned agrees to stall the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIE 5 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.�Signe -4-,-.- ! _ .j Z- •• v Application Approved BY----•-----� ------.�-----�.��!'{-�J•��•-•-- ---.------•-••---------- - 1 ���----•--......_._ Date Application Disapproved for the following reasons----------------------------•----------------------------------•---•-------------•=------._...-•------.....--•--- Date PermitNo........................-------•------------------------ 4 Issued---------------•--------••--•-•-••---••---------------- C a Date ` r r . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ... t.. OF J f.. ...... ( / .mil Trrtj tr4#r of TontpliFanrr THISJS TQ,CERTIFY, T at the IndIrdual Sewage.-Disposal, �ystem constructed ( ) or Repaired ( ) by.... . .. .....f-_..f_ r Installer.5... ................ ......................................... at .................------------- t.'.�--r--..=-'------`'• .---------- �_I r/ l.'................................ .. t_............................................ i has been installed in accordance with the provisions of.T r�oj he State Sanitary;; Code as described in the �7_.application for Disposal Works Construction Permie. 0 ____ .______. dated.;./.r?.`..1-? THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A1GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY DATE.`: _. �.f M T f.. n `Ins'pector__ : ,.;� 1/1i1�1�` .....-•--••--- - . j � .. �. 'r�. ..:..r. J'+.: �* - r. '` {£�J� ��S•,"'E. ,i ss .i'14V'Y�'t'�, it„� j�, .�a'" THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH y ........... '!o OF .�.J ._ Tt!/: '�.:................................... t N ..................... y FEE....................... ti �i��oo�a1 o�ko ��no#raion rr�ntit —� Permission is hereby granted -. ' � y t .... .... • � -`- l '_..:-�.. %......� 1 %!<_ .................................... to Construct (_ ) or_Repair (; ) an Jfidividual-Sewage Disposal System t f % r 1 /f '/'%i c Street as shown,on the application for Disposal Works Construction Pe=it Dated._ . � ' .....-_ --------------•..._._......_.. DATE..— :.................................. Board of Healt FORM 1255 HOBBS & WARREN. INC., PUBLISHERS•