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Home My WebLink About0166 ROLLING HITCH ROAD - Health (2) /gp- fI ' I I " I { S M E A D KEEPING YOU ORGANIZED No. 12134 2-153LGN SUSTAINABLE MIN RECYCLED INNMJIVE CONTENT M CarBfied Fiber Sourcing POST.CONSUMER® wwwsflpmw m g Swim MADE IN USA GET ORGANIZED AT SMEAD.COM _s No.... ......... F�$....a2-:................ THE COMMONWEALTH OFMASSACHUUSETTS BOARD Qg HEALTH : i .... .... ..... -....... OF....... . .... .. fooApphratiou for itipmal Norkii notrurtion Prrmit Application is hereby made for a Permit to Construct ( ). or Repair ( ) an 'Individual Sewage Disposal Syst at: .iJ�, ., n w, fr \ 1 oca on•A ess or Lot'"No. ....... :�.. ..:.... .rt!: .................... ............`. ?: c ..w....................................................... . . .. :. ... . ... .. W ner ' Address J %C ....... .. ....... ....... ... .. .. ....................... .. -�.. .. ........ ........_.__.................... nstaller J - - Address Q Type of Building . ... - �.,. " Size Lot............................Sq. feet Dwelling-6�No. of Bedrooms............. ......... _F�xparision Attic ( ) Garbage Grinder ( ) Other—T e of Building ........... Na_.-,of: ers6 s............................ Showers — Cafeteria a YP g P. . ( ) ( ) a' Other fixtures .... Q W Design Flow........................:. .... .... zilons per person per day. Total daily flow............. -------gallons. ----- - --------- - - WSeptic Tank—Liquid capacity moons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. ...................: Vi th_.. '..'..... Total Length_.__....._ .. Total leaching area sq. ft. Seepage Pit No.. __________.Diametery __'Depth below inlet......_.._.. Total leaching Z Other Distribution box ( ) Dosing tank ( ) aPercolation 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-_--_____--____---. D th to ground water-_-__.__-_-__-...__----.- - • -- J O Description of Soil...•-•-----•----•------- ------ x i -U >. -----------------------------------------------------------------------------------------------•----------------------------•----------------------------------------- •--------•---------------- U Nature of Repairs or Alterations—Answer when applicable..-__--------------------------------------------------.......................................... Agreement: The undersigned agrees to install the aforedescribed Individual SewageDisposal 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. V.g-ne .._.. ...-•..................................•---------... ----•-----••----•............... Da Application Approved BY �a� . ......... ate Application Disapproved for the following reasons:.................... ......................................................................•---------..._...... .........................•--••----------------------------------•--------•-----•------......--•-----...----•-----------------------•-----------•------------ --------•- .............................. Date PermitNo......................................................... Issued----. _.._ ..-- --•- .. .. .... ...... D e f 3hX., I J F No._'_�' '_ FEE.... .... THE COMMONWEALTH OF MASSACHUSETTS E30ARD OF HEALTH r � � Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual SewagexDisposal System at,:, p °` on Tess or Lot No. ................. .......................... ----•�^""""""i'vnertJpT�,� ....,�,,,� ..... ,»:... ..:.... ,.✓ ..`' ..l .. .. .......i.............. :'::: w ..v_'&:.-•f.-+�--'..." _-_....................... nstaller Address ~ 4 Type of Building Size Lot...........................Sq. feet �-, Dwelling iNo. of Bedrooms........... ..ram ....................Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building No. of persons............................ Showers — Cafeteria a YP g -------- ••--••--••--- - P ( ) ( ) aI Other fixtures. d Design Flow................ gallons per person per day. Total daily flow............. ,°��! ._gallons. WSeptic Tank=Liquid capacity 4allons Length_............. Width................ Diameter................. Depth................ Disposal Trench—No..................... W> th .._ Total Length Total leaching area___ sq ft. x Seepage Pit No...y : . .._.-..__,l]lameter :___.`'�. Depth below inlet..... Total leaching area. :___ ft. Z Other Distribution box ( } Dosing tank ( ) aPercolation Test Results Performed by............................................................................ Date........................................ l 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-------------------- D .th to ground water------------------------ P4 •••-_.... " O Description of Soil......................... s�".: 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 health. gnedr.....................- . Application Approved BY--- `: ... - �{:/ :+ A' ate Application Disapproved for the following reasons_____________________ __________________•-____••________-___-______________••_•-•----•-•----•----_----.......... •----•-•-•---•-•-••--•-•-•--••---•-•--....--•----------------•._....._.....------•---.._.-.--•-----•-•------•--_:____.____,_.__..._----•••-•-•---••-•--•••-•--••...______-----••••-•••-•-•••_....._.._.. Date PermitNo......................................................... Issued................................................f...... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OFF fEALTH . .... .......OF..................o,,,,;�?.r,�.....� ................. «.................. At irate n Tomplianr `- �lS 1 0 C -That. le Indiy(dual Sewage sposa - ystem constructed ( ) or Repaired ( ) ` _.. r,i e5 at.r °• a ,ems r j ' •` rtoe�'.'c has been installed in accordance with file pro�ions o Article XI of Thp State Sanitary Code a des * m the application for Disposal Works Construction/Permit No........................ OF ____ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST E® AS GU ANTEE THAT THE SYSTEM W FU ION ATI'SFACTORY. 000 . _-.�DATE . Inspector 1........•--•._._..... �... THE .COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH e 1 .�. *� ... ,r No ... .. FEs :.•--..t........... -0t trnri . n ami �. Permission.is eby granted :.:- y ................... .�..- ..................... to Conk t i .. , ndividuald`S e ag s ` S ' .i o Yat � I � �� tiet � as shown on the application for .Dis�osw I.,Ntr Ks Const:-uc.tion P >t IN � __.` Dated ,19 1,�-. ....,��:..... board 6€-Hcalth DATE....- / --- _ ................. .0; FORM 1255 NOBBS & INC.. PLI BL.i,SH Fr,s