HomeMy WebLinkAbout0073 JUNIPER ROAD - Health SMEAD
KEEPING YOII ORGANIZED
No. 12534
2-1-03LOR
SUSTAINABLEFORESTRY MIN.RECYCLED
INITIATIVE CONTENT10%�
NOW Fib"Sourcing POST-CONSUMER
—W.Sfiprogram.org
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MADE IN USA
f.FT ORGANIZED AT SMEAD-COU
No..........:9...T ... FEs..........v.�."",.....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALT
f ,
Apphraa#ion for Disposal Workil Tomitrurtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( �n Individual Sewage Disposal
System at: . �j j..._.._l
......_.. 1 ...........................�— Location- ddress or Lot No.
K
.... ---- ........................ .................................................................................................
Owner Address
Inst er Address
Type of Building Size Lot............................Sq. feet
U Dwelling No. of Bedrooms............................................Ex Expansion Attic a g— p ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther 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. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
,4 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
R+' --••----•------•----------•-............................................................
•---------
------
•-•-•--•---------..-.------------------------------
ODescription of Soil........................................................................................................................................................................
x
c, ---------------
x ...............=•----••-••--••----••••••--------------•--------••-----------•---•-....-----•--
V Nat tgl�reement:
re of Repairs or lte s Answer when bla=__ 4V��
--
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIL 5 of the State Sanitary Code—The undersigned further grees not to place the system in
operation until a Certificate of Compliance ha ee issued y the board pf h 1
�" � ��3
--
Date
Application Approved By......... -----•-G. -- ( 1i1 ----•-------•---•-•-••-----•- Date
Application Disapproved for the following reasons------------------------------------------------------------------•-----------------------••......•--........---
..........................•----------..............--•-••-•-----•---•-•--•..........----•--•----.......--•------•-...-••----------•-•••----............................................................
Date
Permit
,.No................--
�` THE COMMONWEALTH OF MASSACHUSET7z_,.,e--_ "
BOAR® OF I-IEALT
App iratiun for Disposal Works Tonstrurtiun Vrrmit
Applica.tion•.is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at '�* -
�.:!-ill +--t ' { �.....-- -------- ------------ •-- --- •
............. ... ..... .:_
--- Location ddress .--- -•. -••----.-...•---or.Lot No.
....... ••........ ........................ .....•....
W --/ yJ �� ner Address
Ins lerr '' ;Address
d Type of Building Size Lot----------------------------Sq. feet
V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) '"Garbage Grinder ( )
Other—Type of Building ............................ No. of persons•-- ...................... Showers ( ):..— Cafeteria
dOther fixtures ------------------------------------------------•••-- -••---. „< �.x� >s ...............
W Design Flow......................................:.. gallons per person per day. Total daily flow__.... ......... ..............gallons.
Ra Septic Tank—Liquid capacity gaoris' Width Diameter_____. --___Depth................
Disposal Trench—No. ........... Width...........tt_:4" ,,Total Length ....... .......` Total;leaching area-----& Z:.__.......sq.,ft.
. ff
Seepage Pit No----------_--------- Dlameter� � -_- Deptl '''below i46t.................... Total`lea�hing area................, _.Sq.ft:,
z Other Distribution box ( ) Dosufgw tailk ( '�a
a Percolation Test Results PerforYnel „by x;:: ---- Al ------- Date........................................
a Test Pit No. l................minutes per inch Depth off.Testx°Prt......_..t ._. Depth to g i�god water.._........_.........--
Gi, Test Pit No. 2................minutes per inch Depfih;.of Test Pit.................... Depth to groundi"water........................
�+ ................................. -•...............•----•-•-••-•--------•--------•-•-•---.-•--• .............................
ODescription of Soil.................................................===k ---••-•--=-••=••-•--•-----••---------•--•-----•-------•-••••--- -----------------•--•-----------------.------
� ter. ...
U ••-----•---••....•--•-••---••-•----•--•....-----••-•••••-•---••......----•-•--••---•-••-•------•----••--";� •---•-•� ---•-••--
W -•--•-------------------- ------------
-- - -----_..._
U Nature-of Repai r t s Answer w ble 1 ! `
tr �'
o- .
greement:
The undersigned agrees to install the aforedescribed Individual "Sewage Disposal System in accordance with
the provisions of TIT12 5 of the State Sanitar Code— The undersigned further, grees not to place the system in
operation until a Certificate of Compliance ha a issue y the board h
w
Sign ' "d'R ...----
Date
ApplicationApproved By........ _.. ,----------•---- ........................................
Date
Application Disapproved for the following reasons ............ y
�.�• Y i,' �.� - r s Date
Permit No.:....................................................... " . , X`'Issu'ed.................�.4........ -........................
----•-- ---•= "
e Date >
A ro-
__. «anr�.:a: 3�.K,�. ��.+alV w.:. •yi.
THE COMMONWEALTH OF'I ASSACHUS.ETTS •"
�. N.{r.Y Y ,•a1 G: Ftr
BOARD OF HEALTH
........ ...................... OF...........h..ir.. . ....... ...........4
TrrtiPratr of Bunt lianrr
THI .. S TO ERT�Y, hat the ividual Sewage Disposal System constru&t, or Repaired a
b :; . _
Installer 5p
.. .....
.......................................
has been installed in alcordance with the provisions of 5 of The State Sanitary Co e.as described in the
application for Disposal Works Construction Permit No............/I................... dated_._._ _/• '-7-,f`c................
THE IISUA14CE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS-A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE E ... Inspector..C...__ -.........................................
THE COMMONWEALTH OF MASSACHUSETTS
/�' BOARD OF HEAL ` a.;,.,._.•.. i
7
No........ 7T ... ....../---e�... ..............OF..........h
FEE.
Disposal Igor duns rndiun trio#
Permis ion is hereby granted ----......-•--.---•-•------------------------------•. ................................................
,to Constru ( ) or a ir ( Individual Se ge Disposal Syst
at No'.... ,tz.--
Street
as shown on the application for Disposal Works Construction er t No./__.__ .. x__ aated.__.� -_ '-_..,.-•---.
Board of Health
•., DATE---- ---~-/ _.-7-----------------------------------------=-------
FORM 1258 HOBBS & WARREN, INC.. PUBLISHERS
� T-P
LOCATION . SEWAGE PERMIT NO.
To Nk
VILLAGE
INSTALLER'S- NAME & ADDRESS
B U It DE R J OR OWNER
DATE PERMIT ISSUED .
DAT E COMPLIANCE ISSUED
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