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Home My WebLink About0492 SKUNKNET ROAD - Health 07-3 -00` -- - ., IN S M E A D No.2-153LY UPC M34 amead.com • Made In USA Nbl FOR STRtt WRIATNE CaAllioOF�Soura4w 6q�( / � LOCATION SEWA ERMIT NO. VILLAGE CA I N S T A LLER'S NAME & ADDRESS d�Q_l ® U I L D E R OR OWNER I DATE PERMIT ISSUED DATE COMPLIANCE ISSUED f / f`,f Is 47 D p�-�'. r Fxs.........../..�...... THE COMMONWEALTH OF MASSACHUSETTS J} BOARD OF HEALTH- . �.... \ak..�.d1............OF.................ZC..V'L.n.5.�...................................... AV pfiration for Utz oiial Works Tnntrnrttnn Prrutit Application is hereby made for a Permit to Construct ( L-,}or Repair ( ) an Individual Sewage Disposal System at: � . . ��............................ .........� ......... ............................................................. .... _ .......... Locat'on Address or Lo N ........... �,..... M>...- ............ ......... .�s: .. �....._......................... Addre C. n- -------------- s �� r-�. - c ...... Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.............. ........................Expansion Attic Garbage Grinder ] aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ) a' Other fixtures ............................... . . WDesign Flow......... ....................gallons per person per day. Total daily flow.......... 3-.P................._gallons. WSeptic Tank—Liquid capacityko_o...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 ( ) Percolation Test Results Performed by....... ...... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •---•----•---------------------------------•---------------........-------------•-------•--•.....---.......................................................... 0 Description of Soil........................................................................................................................................................................ x (,) ----------------------------------------------- ------------------ -.-............. ------------------------------------- ......._... ---------- .-------------------------------- -------- *- --------.... 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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system i operation until a Certificate of Compliance has been issued by the board of Health. ned..... .....---x` - Application Approved By �Z.. :. Date Application Disapprove or a following reasons:------••------------•-------•-••--------------------------------------------•-------------:........•---....... ...........••..----••--••...----••-•-•---••-••-•••-----------•---•-•••••---•-----•.................•...--••-•----•--•-----------...•-•--...•------•••-................................................. Date PermitNo......................................................... Issued--•-----------•--------------------------------•------- Date l-. - __---------------------------- No...`... ............... FEs.............................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH n............OF.:.................fa''L.n �S............................................... Alipliration for Dftipottl Workii Tonitrnrtion "rrmff Application is hereby made for a Permit to Construct ( 11KOr Repair ( ) an Individual Sewage Disposal System at: 1 ' ............................ --...... ..........--............................................................ Location Address, or Lo N ry ................J.... ....:t�rf... � ............................. Owi,g Addres i7 ?._.. �'� � _5..........................•- •-----•... �7 fir, ��a.. . ...:......--••------•------•---- __.._rl.................... Installer Address Q Type of Building Size Lot............................Sq. feet U Dwelling No of Bedrooms ,_.., g— . ...............3........................Expansion Attic (t.)b Garbage Grinder Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q, Other fixtures -----------------••--•••.....••• - w Design Flow.........\X:9........................gallons per person per day. Total daily flow--------.j >....................•....gallons. WSeptic Tank—Liquid capacitAoo.`JJ_gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------------t....... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by....... j r .......\L..._..` ..... Date..._�mry 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....................... M •-•••-••••••----------------••---•••----•-•••••---••--...........-------••-•.......----••--•-•------.........................................................O Description of Soil........................................................................................................................................................................ x 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 TITIZ 5 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. jgned. ........ ............. ................................ . Date i Application Approved BY•--�;-�--...............•;=t-----•-•-•-•--••-----•---•-•-•--•-•----....-•-•--•-•---..._...- -•--._.......-•-•....................... Date Application Disapproved to,the following reasons:-•--------•----•-•-•---••----------•------•------•----••---•----••-•-•-------------•------....--••-----•-----.._ -•-•-•••-------------•--•-----•--•--•-------•----••----...---......•••---•---•--••••----........-----••-•-••-•---•-•----•-•---•--...------••----••••••••-------•---••••- •--.....•-••------•------•-- Date PermitNo......................................................... Issued_........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Trrfif iratr of Tomplittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) by----------------- ........... .............................................•---------------------------------------------.........-•----....--•---. Installer at.. ------... ... k l� • ,....... ..._.... .. ....................•••... has been installed in accordance with the provisions of TITIF 5 of The State Sanitary Code as describedin the application for Disposal Works Construction Permit No..... ... ........%......______-___ dated......... ............... .................... y THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....................•----------•-••---......------......--••••-----•-•------•--• Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH NO ...:................. FEE.-:.t�............... �io�oottl ork� �ono#rnr#ion rrmi� Permission is hereby granted _ ._.. -= ............................................................................ to Construct (..,<Or Repair ( ) an Individual Sewage Disposal System atNo.......... ----•---- Street as shown on the application for Disposal Works Construction Permit No.................... Dated..........:............... ........... i ....... / Board of Health DATE...................................... ----� �,� ;// FORM )255 A. M. SULKIN. INC.. 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