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HomeMy WebLinkAbout0000 AMES WAY - Health f1MGI ��y 0 N SMEAD KEEPING YOU ORGANIZED No. 12534 2-153LOR SUSTAINABLE FORESTRY MIN.RECYCLED INITIATIVE CONTENT 10% Cerdfied Fiber Sourcing POST-CONSUMER xwwsgprogram.org s"Im MADE IN USA GET ORGANIZED AT SMEAD,COM F r t° r �a G LOCL.TlOt,1 : SEW&.C�E PERMIT UO. VILLAGE - - - - - - - - - IIvSTQLLER•5 A1C1ME � ADDRESS 1p BUILDER 5 Q l VAF- ADDRESS Dt-\TE PERMIT ISSUED - - — _ — — — — DATE COMPLI &MCE ISSUED 1 ..... Fimu. THE COMMONWEALTH OF MASSACHUSETTS ROAD® OF HEALTH OF............. . ................................................... , ppliratiott -for Dispwial Workii Tomitrurtion Vrrnift Application is hereby ma for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Sys t at cation-Address or Lot No 7 ............................. �-----------•----------------- .•--------------•---------------------....._--------------------•---------......-•--.....--"---- O Address W A_ Instr r Address d Type of Buil ing 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 W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter___.-_...__---._ Depth---------------- xDisposal 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 ( ) aPercolation Test Results Performed by-------------------------------------------------------------------------- Date--------------------------------------.. a Test Pit No. I----------------minutes per inch Depth of Test Pit.................... Depth to ground water.-------.----.--__.-__-- (4 Test Pit No. 2................niinute er inch Depth of Test Pit-------------------- Depth to ground water............- _-_-._. P4 ---------------- ----- ------------------ ------------------•-----------------------•--------•--•---------------•-•--•--- • -•----------------------- ODescription of Soil--_------------ ............. ----•------------------------------•---•------•-•-- --------------------------------•----•------ x ---------------- ------------------------------- -- __ --------------- ------------ -. _ _ _ .. U Nature of Rep a or Altera ' ns—Answer ,n- cable.___ _.._ __._._.. .__-_--.__.. ZIr ------------------ __ - , - ------ _ ------------ ------ -------- --"�",-,".......... __ _.__ _._--.._._°------------._ Agreements: , The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article \I of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b e issued by the borfl of health. 4yjxj r Date Application Approved By------ ... - - ----------- - Date Application Disapproved for the following reasons----------------------------------------=----------------- -................................................... ---------•---------------------------------------------------------------------------•-•-----------------I-------------------------------------------------------- .................................... •• Date Permit No......................................................... Issued.Z/�/­­`­­./­`=x 1_17..V.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH AVVIiratiuu -for' Uhipuml Works Tvtt,,#rurtiiu Prruuit Application is hereby ma for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal, Syst at � � �� ��"' --------- o .. r .' L cation-Address ��¢ or Lot No.� . •--•••-- -------------------- --- s---------------------------- ---------------------------------------•----•-----•-•--------------------------------•------------ Owner �. Address a ---- -------- ---- -----------•----------------- ---•----•--•----•---•-------•---------...____•----••-----•••--------•---•---•------- --•---- p Instay�r Address UType of Buil inge Size Lot............_...............Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) per-, Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' 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. It. Z Other Distribution box ( ) Dosing tank ( ) '-, Percolation Test Results Performed bY......................................................................... Date..............'---------------•-------- ,� Test Pit No. 1----------------riiinutes per inch Depth of Test Pit........'`___._____ Depth to ground water-..-_-.---_-__-.--.----- G14 Test Pit No.12________________minute er inch Dept of Test Pit.................... Depth to ground water._...__-----.__-_-__---- ................ . --------------------------------•-------------•••--•....................................................... DDescription of Soil---------------- -------------------------------------------------------------------------------------------------------------- OWN#x w UNature of P.epa' or Alt era ns—Answer Vencable " _____ ____ -••-- = 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 b e issued by the bod of health. igned... ; = ................... ' ------•---•-------•--•--- ....-•-•---------------•------- Date Application Approved iBY - +er+" J." , ---•------------------- ---------------- r '; Date Application Disapproved for the following reasons----------- ------------------------- ------------------ •----------==---...•-••-----...•----•••- ------------------•- ..---•----- - ---------------------------•--------------------------.-.------•-•- ----------------------------•-•----•------•----- -----••-'•---Date Permit No.--••---••-••-----•------•---------•-----•--...•--....... ; ' � Issued_._ r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Trrtifira#r of (11im litturr TrJIV IS TO CERTIFey � at the IndivWual Sewage Disposal System constructed ( ) or Repaired by---- ' - - staller ------ �r+f�1 = --•------ ° ---••---- ................................. has been installed in accordance wift the provisions of ArticlaXI of The tate Sanitary Codp as descri)ed in the application for Disposal Works Construction Permit No--------- _____________ dated_. - THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUA ANTE THAT THE SYSTEM' ILL UNCTI N SATISFACTORY: DATE:_'__©;.----� ��/ Inspector--::- ...................................---------------------•--- ........................................ tf. THE COMMONWEALTEH OF MASSACHUSETTS �• r BOARD 9HEALTH ..OF....... ........................................... -- No.. ,�!' FEE___, , •--•--- BinVa ! orkii Qlau dit rwi# Permission is hereby granted____ _ ........... , -- ___:_�f✓_...' !G. _ .......................................................... to Construc kf K Repair ( ndividual e Disposal st � -fit:-t�------ -----;�,+G��c-- ---------�------- st as shown on the application or Disposal Works•Construction Permit .-______:_: D, .____ ........... ....... ---- 0 Board of ealth w } DATE... / . -- -------- ------------------------------------ FORM 1255 HOB $ & WARR•EN.. -INC.. PUBLISHERS k�48I