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Home My WebLink About0111 GREEN DUNES DRIVE - Health F- - 0 - - - - 111 Green Dunes Centerville A= 245-010 SMEAD No.2-153LOR UPC 12534 emead.com - Made In USA a y SFI OFWSRMON M SOURGNG WWWSFPWGRAKON Ll 6 t; ............... THE.COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............................................OF............................................... Appliration for Dhipmal Works Tonstrurtion Pumit Application is hereby made for a Permit to Construct (1,11 or Repair an Individual Sewage Disposal System at: .......... . . .. ... .... ............................................................... ..... .... ..................ZZ/......... ----- Jecatio Address or Lot No. ............................... .................................................................................................. 0 ner Addressin �)j (_ 17 ..........................., ............................................... -------- 6:�Ye ..................................... ...tAr .................... Installer Address Type of Building- Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons............................ Showers Cafeteria Otherfixtures ....................................................................................................................................................... Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. 1:4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth----_--_-_._.... Disposal Trench—No..................... Width.................... Total Length..__--._____._______ Total leaching area....................sq. f t. 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................minutesperinch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---.__.....-_--.____.... ............................................................................................................................................................. 0 Description of Soil........................................................................................................................................................................ W .....................................................................................I.................................................................................................................... U W �i ...................................................................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable.-- 15.010.....6-A e.............. ...........S.W_................ .......................................L...........6,k..9.............. .............. ----------------------------------------_.........`......---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TLITU 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance hyasbD enissu I by the board of health. Sign, ............. ........ ....................................... Date ApplicationApproved By.................................................................................................. .................... . .............. Date .Application Disapproved for the following reasons:.............................................................................................................. ......................................................................................................................................................................................................... Date PermitNo......................................................... Issued..................Date................. .............. -------------------------------------- -------------------- No......................... lEs t THE COMMONWEALTH OF MAS$A`CHUSETTS bbA },.. .................................OF..................................................e,..•------.........---...._._....._. .� rplira#ion for Disposal Works Tonstrurtion Trani# Application,iss hereby ,msa-d�e'foorr a'-Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: �/ C..J'"`!G.- �� A Q Y earn �d s i or Lot No. _ r ------- ........ �n � W ` 14 2:G er /! Y-e f Installer Address Type of Building Size Lot._e"............_-----------Sq. feet a -,Dwelling—No. of Bedrooms.........................................:._Expansion Attic ( ) 'Garbage Grinder ( ) aOther—Type of Building _________________•__-_.____. .No. of persons._._x______._____________.. Showers ( ) — Cafeteria ( ) d Other fixtures ---------------- W Design Flow....................._......................gallons per,person per day.;Total daily flow....... .....................................gallons. 1:4 Septic Tank—Liquid capacity............gallons Length_______ ._.� Width.................Diameter ___________ Depth................ W x Disposal Trench—No_____________________ Width_____.................... Total d�ngth Total leachmgu _rea ____ sq. ft. Seepage Pit No..................... Diameter.................... Depth be14 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 .................. Test Pit No. 2................minutes per inch Depth of Test,'Pit..................='Depth to ground w ate r......................... �1 ......................................................-- Description of Soil ----------- = e „W z -� ------------------------------------------------------------- V Nature of Repairslor 7�ilteratiorAr�wer whea�ll�le ............... ---___------_------------_--_-------------------_-----_-•- �� . ----- --- --------------_--- --•--•--`-' ------... ---•----•------•-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System"in accordance with the provisions of T;TL.E 5 of the State Sanitary Code—The undersigned'further agrees not to place the system in •.` operation until a Certificate of Compl'i ance.has_V uq�by t e l .d o heal th w; y l h �" ��, .0 C, Signed I, ---- 171'I. -•-••--r •--•-•- 7 Date Application Approver By-....-••-••......--•- --•--------` ' + Date Application Disapproved for the following reasons: .....................r z , -- :11. F.V gkt i Date tPermit�No.................. ............ ......................... Issued........................................ ............. 1 Date THEeCOMMONWEALTH OF-MASSACkUSETTS A �f BOARD OF HEALTH " A .....................OF.........................................._....... _ Trrtif iratr' "of Tomplian r THIS IS TO, IFY, TJ52%44e,4ndivi�j ewage"'Disposal System constructed ( ) or Repaired ( ) by------------------------------------------------------- --- G ......................----------------------------------------•------------ - at..............................-----:...................................... ----.........-------------•------•- ----••. ••-•---•--...._--•-•---•--- has been installed in accordance with the provisions of TITI#g5.aff State Sanitary Code as described in the application for Disposal Works Construction Permit No__.................._w':_.______.......... dated-............................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE i SYSTEM WILL FUNCTION SATISFACTORY- DATE - �� --_.... Inspector -- --e .............................................................. i t THE COMMONWEALTH OF MASSACHUSETTS, BOARD OF HEA,4-.TH No.. .................... FEE........................ Disposal IF? n oltraa Linn rrani� Permission is hereby grantgc�_._._._. •. r to Construct ( 2epair ( )CI dwidu`aIe e.Da pos�l System' e at No f Street as shown on,%the application for Disposal Works Construction P No.. --- Dated ---- "I -----•- ' "F. k Board of Health 1 DATE .�> FORM 1255 A. M. SULK IN, INC".�' BQSTON L y� k L O CATION ' / SEWAGE PERM T No.\ / f (r rr-P d u �-► ,r 4 �`r �� - VILLAGE I N S T A LLER'S NAME A ADDRESS 4 R OR OWNS DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 6` y_ S y 3k Qa