HomeMy WebLinkAbout0033 JOHNNY CAKE ROAD - Health 33 so k A.Ay Cahe Rd
-s
I
OPendatlenr
r' M13U13 10% P4
t
3
THE COMMONWEALTH OF MASSACHUSETTS
BOARD
......... OF. ..........................
Appliration -for BWVagat Works Towitrurtion Vautit
Application is hereby made for a Permit to Construct or Repair (/an Individual Sewage Disposal
System at:
.................................................................................................
alion= 4dress
... or Lot No.
SAM,—
.. .............. ..................................... ..........................................................
Owner Address
po---------------------------------- . ................................................................
n's t(a Address
Type of Building Size Lot............................Sq. feet
U
Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic Garbage Grinder ( )
P4 Other—Type of Building ............................ No. of persons.-__-_------------.--------- Showers Cafeteria ( )
0.' Other fixtures ..................................................................................... ---------------------------------------------------------------
Design Flow............................................gallons per person per day. Total daily flow___________-__----.-__-----................gallons.
9 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. f t.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by------- --- ----------------------------•--•-•-•--------......-•-......... Date----------------------------------------
Test Pit No. I................minutes per inch Depth of Test Pit.-._-.._.___--__-_-- Depth to ground water.......------..._-.----.
�14 Test Pit No. 2................minutes per inch Depth of Test Pit-.-_-_--....____-_-- Depth to ground water...-------------------
Ix .............................................................................................................................................................
0 Description of .......L 1_
4/e.4/................................................................... ---------------------------------------------
U ---------------------------------------------------................................................................................................................................................
------------------------- ---------------------------------------------------------------------------------g............................................................I----------------
U Nature of Repairs or Alterations—Answer when applicable---- ........Tg 9,-e 0 0�:;S-T..oo'k----- 7,Z,-
----------------------------------------------------------------------- --------------------------------------------------
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 be issued by the board of health.
Sign IV-- - - ------------------------
...........................
Application Approved --- --_-- --------
Date
Application Disapproved for the following reasons:................................................................................................................
-----------------------------------------------------------------------------------------------------
Date
PermitNo......................................................... Issued..._ ...................
Date
--------------------------------
d,...�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 5OF HFALTH
....._�.. �`.---------.OF..... .
Appliratinn -fear Bispwial Works Tonfitrnrtion Vrrntit
._Application is hereby`made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at:
... J ......A....�/ ..............................................................!l(>°
Location ddress _ or Lot No.
/� Owner T Address
�_
•---•--•--•----•----•----- instal-]
nst---•-• ------------------------------------- .....�c.... .__..._._.....Ad res.s------""---------•--------------•----•-----
� Installet� Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
P4 Other—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-.__-__.-----
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--------_---------- -----------""------------------------------------"••• Date........................................
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---------------------
. ._.
fY ' ....----••-•--------------------------••-•--------"---"-•-"•-----"--------........------......----...--•---•-••--......................""--"-..•... --•"--.
xDescription of Soil--- _=�"1�-L/-------- �►�' ` ---------•"------------------------------------------------------------------------------------------------------
U --------••-•..............
W
x ------------------"-............ "--"--"--•--"""-.......--"-"-"-•""--__.....-•""""•"----------------"""-"""---................--"-------"-----•-"•""------""---•-"""""-""""--"""""""""" ---------------
U Nature of Repairs or Alterations—Answer when applicable....__la: _ .___ !?_ 1_ .%-.._.� L? �.......t
r` t
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--,,,9/. s A �-------------------------
Application Approved BY �/,= 1 '�`�------
'-' ------- �-`----ate-- 7�
Date
Application Disapproved for the following reasons:----"----------------------------------------------------------------------------------•""-------•-"•-----------
-----------•"-•"--"•"•""""-""""""•"-"---•-"""•--...."•-"""-""-"-""""-""""----•--------•••--•---------•••----"--•-"••"----"""--•"-"---"-•-•--""---"-"" -------------------------------------------------
Date
PermitNo......................................................... Issued............ --------- .................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALT
../--................................OF............ ..........L ..........1.......................
C"rrtif irntr of 011,11mplittnrr
THiS S TO CERTIFY hat the Individual Sewage Disposal System constructed ( ) or Repaired
2 -��j _7- .....................
talle
at.. �
has been installed in accord ce with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.{�?L�_f � ��_____________ dated...... _�........__.._.
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
_.OF........... ' _...��
' �. -1.
N o. . /
%'Wo tt >ark nu tr tnit rrntit
Permission is hereby granted__-.,_. _ .__t _.��•..._ _.__/._.___K--�-± - �
�1 r,. -------------------------------------------- "---••------•--•-••-•
to Constructlo ) or R . it ( an Individol S age Disposal S
at No. l.e;.. �'�vt� --- liL tom .c-- ' -c
as shown on the application for Disposal Works Construction P_r No- ..............
.. — r'
— Y B
DATE-----?7.. -.... "-"-7e............................................ oard of ealth
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
LOCATION SEWAGE PERMIT NO.
VILLAGE
INSTA LLER'S NAME & ADDRESS
1-E-Dllr 0R 0 W N E
r
DATE PERMIT ISSUED
. ,f � 76_
DATE COMPLIANCE ISSUED od74!�
J