HomeMy WebLinkAbout0180 EVERGREEN DRIVE - Health f'f7 �rS To s h7 r V /V
LO TI SEWAGE PERMIT NO.
VILLAGE
INSTA LLER'S NAME i ADDRESS
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i UILDE�R OR OWNER
L-p/1/'�rr'
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
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No...._..... 1.......... FE's.........�..................
THE CO.MMONWVEAL'T''9 OF MASSACHUSETTS
BOARD OF HEALTH
..........�_OWN...............0F.....0AZ(,1/-,T.-A B ----------....................
Appliration for Di-41taa.sai WorkB Tomitrurtiaaan rumit
Application is hereby made for a Permit to Construct (V or Repair ( ) an Individual Sewage Disposal
System at:
........ V d i� = ...................................el ............................................ . . :.-•-----------..........------
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----•-•............... .--..L ?A r +� ...---- ..•--- r-- .......-------.... 1> 1 ----...�._ _.._..
Add
w14t.7—...C.. . . ...... .............. . ...... .. ...
Installer Address
PQ
V Type of Building Size Lot__1 R� &...Sq. feet
Dwelling—No. of Bedrooms............... ........................Expansion Attic ( ) Garbage Grinder ( )
pa., Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ....._--•--•--•---•............. .
Q --- ------------------------------
DesignW Flow.................. ..................gallons per person per day. Total daily flow------------------- ...............gallons.
WSeptic Tank-L Liquid capacity!-g-�_----.gallons Length---------------- Width................ Diameter---------------- Depth................
x Disposal Trench—No. .................... Width...9c............. Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No,.-_-.�-------- Diameter--------*-------- Depth below inlet... _ To 1 1 Ching area.... ...sq. ft.
z Other Distribution box ( � Dosin ank ( ) A ��' � '
Percolation Test Results Performed by___________ ________ _ _a.. ,_-�i��0 _�� Date..__��� hi...___.__._._..
4 Test Pit No. 1.... ......minutes per inch Depth of Test Pit......iZ...... Depth to ground water........"..........
(X4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
W .... . ........... ............... _...Y Ir --••'••"---••------------------------••••----------------
O Description of Soil------ -� '� ..............i, . ........... ....- 2 -- ----------------------••-----------------------------------------•---..
U -•--
W
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of:TTLZ
p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has e i e y the board of health.
Sign -.-- --- .................•••-••••---------•--...-----------------
Date
Application Approved BY _ --- ....=1 .. = �_-.Z, -
� Date
Application Disapproved for the following reasons: ------------------------------------------------------------------------------------------
•----------------------------•--••-•----•••••---.....---•----------------•-•---•--•--------•------------
------------------
Date
Permit No......................................................... Issued---J_74.49_ 1d......................
Date
4
r- THE COMMONWEALTH? OF MASSACHUSETTS
BOARD OF HEALTH
..........�Ow.. ...............OF.... ..............................
Applirlatilan for Dispvii al Works C omitrurtinn Prrutit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at: '
Location,-Address or Lot No.
—� t._ .------------------ : ...±I.. .........................
Owxlez IV Address
i
Installer Address y
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
Q, Other fixtures ------------------------- ................................................
4Z6
W Design Flow________________....._..._........gallons per person per day. Total daily flow................... .............gallons.
WSeptic Tank-1 Liquid capacity!•' .gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width_.--_-f.............. Total Length.................... Total leaching area---------------.....sq. ft.
Seepage Pit No---------- .......... Diameter........ 1........ Depth below inlet...i9k......iY Tol,�l l%hing area...��...sq. ft.
z Other Distribution box ( � Dosing tank ( ) Y''
`-' Percolation Test Results Performed by. I ke..'' . '_ ' --- Date.___ _ _ ..........
a minutes per inch Depth of Test Pit------- ._.___ Depth to ground water........................
Test Pit No. 1___. _____
GZq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
,... ................................
o . - a -
� .:• -4 ��
Description of Soil--------•------------------- -----------r.. 1!� . .. -----•---f-----------------------
----------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable.-----------------------------•----------------------------i--_----_-_--_---_____---_----.--__.
•-------•-------------------------------------------------------------•------•---.............--------••--------------------------------------......---------------------------------......--•-•__----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of:T`T._."
p 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.-- - -
Application Approved By_ // � --- ----------------------------------------•- -.2 3- c�
-----------------•-----• Da
Application Disapproved for the following reasons:.......................
•--------------------------•--------...............................Date---.......__._
•--------------•--------....----------••---------•------------------------•-----•-•-•-----•--------••-----------•-•------------ ----------............................................................
Date
PermitNo......................................................... Issued_......._..........................
Date
`a
THE COMMONWEALTH OF MASSACHUSETTS
_.,..... BOARD OF HEALTH
. ..............0F........ .... � _�.'` .�- �°...........................
1,11rrtifiratr ,af TrrntpliFanre
THIS IS TO .ERTIFY, That the Individual e wage DisposalIvfsteW constructed ( or Repaired ( )
by .......... -
� Installer
at--------------------- ....................................... ` :d t-,5
has been installed in accordance with the provisions of 'r j of The State Sanitary Coe as described in the
application for Disposal Works Construction PerT� i No._ __ __.___ �___________________ da.ted__-......_'.. .:__.__._.____._.
-,THE ISSUANCE OF THIS CERTIFICATE'SHALL NOT BE ,CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.: f
DATE............... ......1 - �. ....................... Inspector.....
' THE COMMONWEALTH OF MASSACHUSETTS
. . BOARD OF HEALTH
too )� f �; "'ETA --
#! . ... ...........OF.....................................................................................
No......................... FEE........................
t I nrkv Tong#rnrfiv �ernti
Permission is reby granted----- ...... ----- ............................
to Construct ( kof or,Repair ( ) an Individual Sewage Disposal System
.
atNo...........................
Street (J-
"" as shown on the application for Disposal Works Construction Per.. it No/ -��__..
_ ..�__ Dated----(~ - -
i ! -ram= ---- `
` Board of Heajt��
DATE .............
. ..
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