HomeMy WebLinkAbout0012 ELDRIDGE AVENUE - Health (2) 7
No.............
------ FA ...d. ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OR HEALTH
7 UGI� ..........OF......... ....................................................
�/0� Appliratiou for Ditiposal i6orks Tonfi#rudion Prrutit
Application is hereby made for a Permit to Construct (V) or Repair ( } an Individual Sewage Disposal
System at:
__JJ �e �`'�7 Location-Address yy .j or Lott No.
..^:.o 6?. l.. . 1......!.� p�! G•.J.:�.Ll. N ...A o �..d..5(.... ...Z..AA.1VJ..S..........................
Owner Address
.........................................................Installer Address
Q Type of Building Size Lot... ...:.Sq. feet
Dwelling'!eNo. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building 4AN_C°__.P..... No. of persons............................ Showers (3.) — Cafeteria ( )
Pa Other fixtures ...............- --••--•---•---
W Design Flow....:�.d.. ...........................gallons per person per day. Total daily flow..........................._................gallons.
WSeptic Tank—Liquid capacity/iP_P.v.gallons Length................ Width................ Diameter......._........ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No..�__-- Diameter.................... Depth below inlet.................... Total leaching area..................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........................
P; ..................
Description of Soil---------------------s .........
W
UNature 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 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 issued by the board of health.
.r,� /4 7 71
Signe
4. - •••--
.....
Date
Application Approved By----
------------------------------------------------------------
Date
Application Disapproved for ?fie following r sons---------------------------------------------------------------•--•-------------------••--•......•---•-•........
...-•-•-•-•-------------------------•-----------------------••-•-•••••---•---•-----•.....-
Date
PermitNo.- ..................................... Issued........................................................
Date.
,J
No............' .. 1� ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
{f''l��t" .... OF........ "...... . ......... '..".
Appliration for Bisposal Works Towitrurtion unit
Application is hereby made for a Permit to Construct o ) or Repair ( : ) an Individual Sewage Disposal
Systern at:
------ ----....-_.... .............. ...... ...__.....:......
... °.._ _... .. ..:.. ....... ....... ............................-; 1! r Address
......................... .............................._......... ...............................................__.........-�� °------•-
Installer Address � '� Z9el"fi
W ,
Type of Building Size Lot............................Sq. 'feet
�-, Dwelling—No. of Bedroom .......... .................................Expansion Attic ( ) G.Garbage Grinder is ( )Other—Type of Building ��'/�fG � .... No. of persons.................. Showers
Q' Other fixtures .........................................................-•
W Design Flow......... :, .....gallons per person per day. Total daily flow.....................
�••-•-•---•--..._..--•--. ............................................gallons.
C4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No.................... idth.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No._._--.-, Diameter.................... Depth below inlet.................... Total leaching area...........:......sq. ft.
Z Other.Distribution,4`'r`` ) Dosing tank ( )
'—' Percolation Test Results Performed by.......................................................................... Date........................................
Test 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........................
PI' ........... •..............•-------
O Description of Soil ,..:.. - .................................................. ..................................................
................... ✓ ...• - .....N _.
U ............................................................................. ......................... ..........._............_.._._
•..........................................................................................................................................•------.....................................................
UNature 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 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 issued by the board of health.
S �
_ Date
ApplicationApproved By........... f,. . ......-, ......................................................... .......... ............................
Date
Application Disapproved for tife'following reaAns---...............................................................................................................
..-----•--------------------------------------------------•--••--•-------------............----------•-....----------•------.:.------....----------------------••--••-----•-............................
Date
ef• •
Permit No........... .. ...............................
..... Issued........................................................
Date
THE COMMONWEALTH 'OF MASSACHUSETTS
BOARD OF HEALTH
OF.......... ......................................
(Urtifuttte of tlootphattre
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( % ) or Repaired ( )
b r° r r r � �,
091,
Installer
7 f�/�
at. 1k/s l�f�i 1..._:.: sir F'J b' 1.-.:-.:"r r
_.......f _L......_ .,. ..._.._.S_._..... .*-•............. . _'.__......__......_........._...._._......_'.'.'.._..._..._."."'........"....
has been installed in accordance wifk5 the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit ?fro...�,f:�y..:�......................... dated.____.:__`_r'_'=�___._-'_�".
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......................•---•---..........------•----•---•---------............. Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No. ........... FEE.........................
Rapaiiab :Iforbi (fonotrurtion Prrmit
Permission hereby granted.......-----:': ` � . f ...........
to Construct* ( ') or Repair ( ) an Indivi`c(txal Sewer "Disposal System
Street
as shown on the application for Disposal Works Construction Permit No............ .a.... Dated...; _`..::::....:..:.....................
-------------•--..........--------...----------.........------:---------•-------.....---•••-••-•---...,
Board of Health
DATE................. ---------------------•................------•...---•--......... . 7
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS