HomeMy WebLinkAbout0035 FOURTH AVENUE - Health �4venue
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L'0 C A T ION . � SEWAGE PERMIT N0.
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VILLAGE
NAME i ADDRESS
INSTA LLER'S N 4 s
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3 U I L 0 E R OR OWNER
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DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
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ISSESSOR'S MAP NO. j PARCEL
LGCAT ION ,11 SEWAGE PERMIT NO.
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VILL *GE
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ALL ER'S NAfME & ADDRESS
kill UILDER OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH'
e N fiv4�� A ulirtt#i for 11ispnsal arks Tunstrn.rtiun rrutit
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Application Fistiereby made for a Permit to ons uct )( �.or,R i bran I i dual 'ewage Disposal
System at: � - - V f..c.•.• q � ._... I�4
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.- ...... ............--.... ..... � .-•----. ... ......................---------._
Location-Address or Lot No........................................: ..•--••-----------•..... --•--•.. ••. --. .. . _................._..
Owner Address
aIZ4. � u.�r's...•.• �---cf-- -----------------®`----------------------•------
Installer Address
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 .................................. .
d ...........---••-.......•---------•-
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........................
a .....•---•---•------•--•-•--•......................................................................••-•--...---•....................•-•-------.....---•-----
0 Description of Soil.................................. •---------•----....-----.....-----•......------------------------------------------------•-------------------------............•---
x
c, ------------------------------------------------......--------------------------------------------------------------------------------------------------------------------------------------------------
x --••-----••-•--------------------------------•---------•••-----•-••-------..--•-•------•-----•---•------------•----------•-------••--------•---•--------- ......................- .
U Nature of Repairs or Alterations—Answer when applicable._.__ �� ___. _�l____ !_C...__ . .......................
.....r--442 ......41...�� ���� .5.��?tee-- �
------------------------ ..
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal. System in accordance with
the provisions of iI'IlE 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- � .1f- ............................... ��%`...v......
Date
ApplicationApproved By...............................:..................................................................
Date
Application Disapproved for the following reasons----------------------••-----------------------------•--•------------------------------•---•-----••••...-••--••.
..........-•--------•--------•--•----•...................•-------------------------..-.....------------..._...-•----------------------------------------------------------------------------------------.
Date
Permit No.....
46 d d
Daze
Noh:..G.Q`_'-... Flcs'.� v.0..........._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD( OF HEALTH
Appliration for Disposal Works Tongtratr#inn rrnti#
Application is hereby made for a Permit to o ruct ( ) or R aIan d '
u ewage Disposal
System at: ri
/
Locati n-Address or.Lot No.
�. r4
r.._.............. . .eL---------------------------------------- -----
a r -------
Owner 4 Address
r -.... _..." ....1"�r�--------------------------------------•--•----.. .._/_- �� s �
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
a Other—Type T e of Building No. of persons............................ Showers
P.I YP g --------•------•-------_..-• P ( ) - 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. ff.
Z Other Distribution box ( ) Dosing tank ( )
a
Percolation Test Results Performed by.......................................................................... Date........................................
,.� Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.................._--_-.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-I
DDescription of Soil----•-•-•--------•................................: t- .......................................
U ===-= .....................................
VW ----------- >� �°�•
Nature of Repairs or Altat.i�ns—Answer when applicable____,E` ap _' ._. CC__:__e! .!1 �`~
Agreement: n
The undersigned agrees to install the aforedescribed",Individual Sewage Disposal System in accordance'with
the provisions of TITI-E 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 boa A of health.
Signed��` -- = !�
Date
ApplicationApproved By—...............................................................................................
Date
Application Disapproved for the following reasons-------------------------------------------------•------------------------------------------•--••-•--------••--
.............................••--------••--------------•--•..._....-•------•---•.._.........-•-------•-•••--------••--•••-••----•--------•-•----•-•-•-•--•--•-•-----•-•-••----••-. ---•••••----••-•--•--
Date
Permit No......................................................... Issued_ .� s
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARDy OF HEALTH
.....,/ �' 7.................OF l". ............................................
Tn#if irFa#r of Totnpliuttrr
THI`$.I O RT,I,FF That the Individual Sewage Disposal System constructed ( ) or Repaired
by............ ' - ..::.�`.�:..- _.._-.":�..................................................................................................
.r iistaller
;d
has been installed in: acco dance wit t ze provisions of Ti
5 o The State Sanitary Cc je a escribed th
application.for Disposal Works Construction Permit No. .._ !-?_•"_�`_�___. '� dated-- - ------------- �.
THE ISSUANCE OF THIS CERTIFICATE SHAL NOT-BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTIO SATISFACTORY.
DATE...- ............................................ Inspector... ..__ _
THE COMMONWEALTH OF MASSACHUSETTS
BQARD�OF H H
,. LL
.-
N o. .:.................... FEE �..2
Disposal /kn witnution rrmft ,.--
Permiss>on is hereby granted !/. .. ....... :........Pit.tJ-C, *......
to Construct ( ) or p r (f s)�an Indivld al Sewage > posal System A`'
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reet
as shown on the application or Disposal Works Construction eer it ___: .. __.___ D .1. .............. � ._.
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6 D -_•� 7 Board of Health
DATE................ --•-----•-/ 1�... ---/-..................................
may,...
FORM 1255 HOBBS & ,"ARREN. INC., PUBLISHERS `