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Home My WebLink About0014 JOHNSON LANE - Health (2) l�f A rd6n 10 e , (,end. / /q3 � 6-77 J - - 05 =4r- "7B I ' I i I I I i i it I S M E A D KEEPING YOU ORGANIZED No. 12134 2-153LGN ( SUSTAINABLE FORESTRY MIN.RECYCLED 7 INITIATIVE CONTENT 10% Certified Fiber Souming POST-CONSUMER® wwwsfiprogram.org SR-012W MADE IN USA GET ORGANIZED AT SM€AD.COM No...... �� 1 � Fics. ................... THE COMMONWEALTH 0 MASSACHUSETTS BOARD O HEA TH l � l^'t �.OF........... . ....... .................... Appliration -for Mfipwial Works Totuitrurtion Vanift Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System t - �, canon-Address or Lot No. Wo, . .... ...................• .......... ......--------•- Owner o ---------------------------•---•---•--------Address Installer Address Type of Building Size Lot............................Sq. feet Dwelling. No. of Bedrooms:-------------_--------------------_--------Expansion Attic ( ) Garbage Grinder ( ) aOther— ype 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--------------------- ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area-_---______,__-sq. it. Z Other Distribution box ( } Dosing tank ( ) aPercolation Test Results Performed bY.......................................................................... Date........................................ ,� Test Pit No. L..-------------minutes per inch Depth of "Pest Pit____________________ Depth to ground water.._________..__._-._.... (14 Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water__._.__..__..__._____... a (-�•------ O Description of Soil---------,1 x W x ----- -•-------------------------------------------- V Nature of Repairs or Alteratio : Ans er,when apWica _..e.. �; _ _ _ _________________ --- -------- ----------------- 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 Complian4has iss d by the and of health.) ----------- ••. •--_..._ Za..',��elK A lication A roved B � _ _ _ --V/�'o ...---- PP PP Y---... - - ---- �.G.�-�•- _- ------ --------------------- -------------------•--------•-------------......................-•----. ......---- Application Disapproved for the following reasons___________________ __.. ----------------- Date PermitNo......................................................... Issued........... ,ram`..........•..••---- l 04 No...... :_ Fps. . ......_ THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEA TH ..........OF........... _... r. Appliration' -for Bi_gVosal Works Tottstrurtion Punift Application is hereby made--for a-Permit to Construct ( ) or Repair ( ) an.Individual Sewage Disposal . System �t�.. -••--- cation.Address or Lot No. Owner Address W . Installer Address Type of Building Size Lot.............................Sq. feet U Dwelling No. of Bedrooms--------------------•_-_--•_______---.____.Expansion Attic (, ) Garbage Grinder ( ) Other— ype of Building ............................ No. of persons..-:------------------------ Showers ( ) — Cafeteria ( ) Otherfixtures --------------------------------------- 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. 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........................ D Description of Soil--------- - . ___ _ _ _ _ :. �., . w x --------------------------------------------------------------------------------------------------------------- -- ,.... -----------------------,:--•-•--•••......--- U Nature of Repairs or Alteratio s Ans ;when le..... Qi ------------------ Agreement: . ---- ------• -- -- ---- - -•-- ----- •--- The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance witl,. 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 een iss d by the and of health. ?'"}� � ' ` ePP PP Y ---------- A lication A roved B "-.•-.___-- ,/d7 ..._... Zj e Application Disapproved for the following reasons.---•-•-••-----__.•-••--•-••--•---••--------------------=••-----•-•-•--...•-•---------•-----------•-•-...--•••---- ..........................................---------•------------------.......». µ Date Permrt.:No. ==_:... Issued.F =-•------•--•--....._--••-- Date � J THE COMMONWEALTH OF MASSACHUSETTS +g. BOARD F HEALTH .............OF ....16E...e'r!!:... ........"................................ (Irrtifiratr of 01,lormlitiatta THIS I . CE " FYI at the Individual Sewage Disposal System constructed ( ) or Repaired by Installer �) has been installed.i accordanc with t provisions of Article XI of The State Sanitary Code.as descri ed in the application for Disposal Works Construction Permit No----......... dated........ . . _.,� �:.. .__._.... � . .Z THE ISSUANCE OF THIS CERTIFICATE SHAD NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................. Inspector..................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH / i OF... ..... ..:. .. ................. T4� i No. + f.✓` FEE /' " �i��g 1 rk,� �t�tx�tFti�$t �rrmit Per ,issio is hereby rante --- .---. �_.(/ -.----- .......................... ................- I�1 g to Cons ) Repair an Individual Sew oral Syste at No' ••-• -- •••• --- •.............. Street as shown on the ap lication r Disposal, orks Cons ruction P t N Dated___ Boa d of Health DATE �. .. ... �.._�-- =--------- --------- FORM 1255 HOBBS}&.,WARREN. INC.. PUBLISHERS