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Home My WebLink About0091 HAWSER BEND - Health 9 f FiGuJ�� Bend CeAjvrviit SMEAD KEEPING YOU ORGANIZED No. 12534 2-153LOR SUSTAINABLE FORESTRY MOV,RECYCLED INITIATIVE CONTENTIO% Cer6fied Fiber Sourcing POST-CONSUMER --Sfipropranwrp wn290 MADE IN USA GETORGANIZEDAT&NAMN No...... s THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA T t.G !��t-".O F..... .. ............................................... Appliratinn -for Uinpnnttl Works Tow5trnrtinn Permit Application is hereby'made for a Permit to Construct or Repair ( } an Individual Sewage Disposal System ..................... -------•------------- -------------- ........................................-----------'---------------------.----------------- cation ess ---... LotrAlo 2F ......... ...e.. ..e.............•................ ..................- -• •-•- ---•-- Or ..___.. Address r'--------••-•••. -••-••---• ---•--•------------ -- •- Installer AddressTyp Size Lot..44_1-aa-_._F___Sq. feet U Dwelling—No. of Bedrooms.............. ............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures .... ...... ...... . W Design Flow............... `-G_--------------------gallons per person per day. Total daily flow-___-_-____---•.�0.®_-___._.._-.-_.gallons. WSeptic Tank—Liquid capacit/J O. lons Length________________ Width................ Diameter------._....... Depth_.............. x Disposal Trench—No.................... Width___ ------------- TQt9,Length_.._.__.__._....__.. T 1 1 ping area--------------------sq. ft. Seepage Pit No.... _ / i [ete ________._------ D et.. .....n......-.... aching area..-3_1F__sq. ft. Z Other Distribution box ( ) Dosing tank ( ) �� .G.�� ►" Percolation Test Results Performed bY........... .............................................................. Date--------------------------------------- aa Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water.._:--.__._.._-_._.-.-_ (i Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water_--.---_-.---___--.___ P4 ...................... --------- -----•. -----•-------••-••-- -- ------- Description of Soil - ' �'`�� ` - -''�--- � ------------------ U W --------------------------------------------------------------------------------------------------------------•------------------------------------------------------------------------------------- VNature 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 ealth. a Signed- ------... •---•e�`n--• --------------- -----71,A � Date Application Approved BY ------ Date�" ..- Application Disapproved for 'the following reasons___________________________________________________________________________ ------------------ ------------ ---------------------------------------------------------•-----------------•--•-•-------••-••------------------------------------------------------- -------------------------------------------------- /•1 Da Permit No. Issued ..................................................(/ 7 7 Date to Date LOCATION SEWAGE PERMIT NO. ,4r �i l�,li-w Nv VILLAGE INSTALL L�i�.Y,;ME & ADDRESS 1082 Old Stage Roa4_ �� .082.O_d Stzge 0 5 itoad Ceuterville, Hasa. Vent, ;to r „T BUILDER OR OWNER Z*vka,ml lee D A T PERMIT ISSUED DAT E COMPLIANCE ISSUED r � �� a 1�/ N �. �� cam' i 4� ' M1 No..... .............. Fwic.Z... .................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HIEA TH,/ ....... i A .....OF. ...... .......................... Apphration -for JM!qpwial Evrka Towstrurfillit Vrrnift Application is hereby,,'made fora Permit to Construct,,(-'—)or Repair an Individual Sewage Disposal System at:,,,,. L ................................................................................................ ................................................................................................. Location-Ad6ess or LoYNo. " kK1 ........................................F..................4_-e,— ....................................... ..................................................... ..... .................................... owner .. .. .✓//,X—e ---------------7-------Lra ---*-----------,------------------------------------------------- ---------------------_- .. ................................................................. Installer Address U <� Type of Building Size Lot../----5_1.__t..._�..5? Sq. feet Dwelling—No. of Bedrooms---------eV Expansion Attic Garbage Grinder ----------------------------- -1 ;14 Other--Type of Building ---------------------------- No. of persons_-___-_----_---.-.-__---- Showers Cafeteria 0. 4 Other fixtures ---- —------------------------ ------------------------ Desigp Flow_____________.�- Ala 0 .. ........................gallons per pet-son per day. Total daily flow--------------------------------------------gallons. 0 e, -uik—Liquid capacity/I........Jhons Length!............... Width..-__....._..... Diameter..............__ Depth.---_----.---. ,�i� S T, Dispersal Trench—No----------.......... Width------------------- Tott�_Length__ T fal le/ching area------------__....sq. f t. i I ------------------ Kt-a?/ieachin-area___',q_R__sq. ft. Seepage Pit No----- Depd-r,115,61-o-W-1 nlet --------- --- A -77 Other Distribution box il' Dosing tank Percolation Test Results Performed.by--------------------I---------------------------------------------------- Date------------------------------------ Test Pit No. 1................minutq`per inch Depth of Test Pit......_._._......_.. Depth to -round water........_............... Test Pit No. 2................minutes:per inch Depth of Test Pit.--_-.-------_--__-_ DepS`to ground water--.-..-._-.---.-__-__2 ...................... -------- --------------------^.......ae------- 0 Description of Soil-----77�---le! — A-, .*e=. , �4 iL:L7-------I ----------------?- --------- ------------------------------------------------------------------------ U k-Jel-4�. ---------------_---- -------------------I------------------------------------------------------------------------------------------------------ -------------------------------- ............. 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 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. Signed" ------ .......... ----------------------------- -------- ...... Date Application Approved By----------- ........ -- ---- -- - --- ..... .. ------- Date Application Disapproved for the followinj^,reasons:.,.....11;---------------__ __77---------------------------------------------------------------------- .......................................... -------------------------------------------------------------------------------------------------------------------------------------------------------------- Permit No. 'I...................... Issued...... ---------------------z 7 .......................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......OF... AC-1....................................................... TrrF.1-firatr of Tomplialtu THIS IS TO CERTIFY, That the Ifidividual Sewage Disposal System constructed ��01 Repaired &01 by............A'- ..........:E_�................................ ...........................................................................7.................................... Z; Installer at........ ...:72 n...... Z7---------I— ----- ............................................................................. has been installed in accordance with the provisions of 6 11 of The, State Sanitary Code as described in the application for Disposal Works Construction 2......... Y.-A- �;," Permit'N. 0 -------------- dated----- ................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.....................................`__X.................................. Inspector------------------------------------------- ----------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................. ..........�' .............................. o......................... X FEEZ ................ DinVatial Norkii Qlangtrurfivit V�rmft Permission is hereby-granted . .z!�, ............................................... 0, _�-- -------- ----------------------.... - to Construct or Repair an'Individual Sewage Disposa],System;�,7 -7/— at No .......... ........................ rrint - ----------- Dated-_197�A- 7;7 as shown on the application for Disposal Works Construction i-Pt ----A -------------............... _2�Akzle-------------------------------------------- B..,d of�41th DATE................................................................................ C-OOF FORM 1255 HOE38S & WARREN, INC.. 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