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Home My WebLink About0401 ROUTE 149 - Health (3) LAI 1 qC rlk31p Old Pow-- zoacl i i i N S M E A KEEPING YOU ORGANIZED No. 10334 2-153L MADE IN USA GET ORGANIZED AT SME.:AQ.COM No...YY....� :f0 l./ b q V n FE$....20.............. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HE tL ............OF.........- �.........- % ' _................. Allp irFatiun for DiupuuFal Works Tuntrnrtiun Vvermit Application is hereb ..made 1 r Permit to Construct ( ) or Repair an Individual Sewage Disposal System at _ . _!. _ .. ... - - - -- ------------------- ............ .... Locatio Ad e s T't'Ro t W Vp. v Owner \ W�t%, �FL�• 1 •• .p3(r�ejs .............CO.— -�-_ ._.... ......... ....................... _.__......__..__._.!_..._ ._._ -.A.:!4... .6...`____.f..•..•.....-_______'�. Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) 4 Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures - Q -------------- - W Design Flow............................................gallons per person per day. Total daily flow...................................:........gallons. WSeptic Tank—Liquid capacity.l ftallons Length------_------- Width................ Diameter................ Depth................ x Disposal Trench—No, -•__________________ Width..........i_..._._ Total Length.................... Total leaching area.- ------------------ 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........................................ aTest 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-------__-_-___-..______ Pd ----- -•----------------------- -�-•---------------- -------........-----•--......-------•-------......................................................... PDescri tion of Soil 4 ------------------------------------------------------------------------------------------------------------------ x ------ W ---------------------------------------------------------------------------------------------------------- ------ -------- -•---- % V Nature of Rep irs or Alte ations—Ans r when applicable____ ._ ` ______�__�® �Ss�vt� S - w r L L........................ r.....---•-•..................•- •�--V---- �> ............................. k--••--•--••- i 1= ................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with Tr1F� the provisions of TuIL LE 5 of the State Safs Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance h nisjVed by th boar of heat . ..•---------------....---•A----------------••-•-•------------•------ Date Application Approved By................ '.. .. ---= ----------------------•--------- ----- ` Date Application Disapproved for the following reasons:-•-•--•-•---••-•••-•----••-•--•••••-••-•-•------•------------•••••-••---••-•-•-•--•-------•-••-•.............._ -------------------------------------------------------•----................------------......---------•----••••--•--•-.-•-•••••..-•---•-•-•-•--•----•-------------------•••-----•......•----•--......... 11�17_� Date Permit No. Issued.. t.-�-• �� =----------- Date No....A./ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE ,LTLJ ...............OF.........? ........................ Appliration for Uiiipasal Works Tomitrurtion "amit Application is hereby made for a Permit to Construct or Repair TA,an Individual Sewage Disposal System at: .... k ................. .............................. ....................................... .................................................................................................. Add ess r C� 0 #ot 10 - .............. .................................................................................. Owner S ----------------- V�t 11 ........ k-�0 ----------------------------------------- ............ ......... ---------- . ....... --------f-------------------------- Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder ( ) �_4 PL4 Other—Type of Building ............................ No. of persons...._.............__._..____ Showers Cafeteria ( ) -<PL4 Other fixtures .................................................................................................. ----------*------- -------------------- W Design Flow............................................gallons per person per day. Total daily flow----------------------------------_------gallons. 1:4 Septic Tank—Liquid capacity_.1_9�9.�gallons Length................ Width___..__..._..... Diameter________-___-__- Depth................ Disposal Trench—NTo. .................... Width....:__..._!. ....... Total Length_........._..._..... Total leaching area....................sq. ft. Seepage Pit No......6----------- Diameter..... ---- ---T'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-----------------_----- Test Pit No. 2................minutes per inch Depth of Test Pit______----_--___-_-- Depth to ground water_-____...._.__.......___ -------------------------------- -----------------------------------*............................................................................. 0 Description of Soil................ .. ..........A ................................................................................................................. ................................................................ t U -----------j------------------------------------------------------------------------------------------------ ................ ................................................................................................ ............................................................ ... .............-Repairs or Alterations k when applicable- _ ----- - U Nature of - nsNvsr I D_.............................. ................... L ...................................................................................................................... ------i_-------------------_-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'T'IE iof the State Sanit Code— The undersigned further agrees not to place the system in e operation until a Certificate of Compliance I .rs �4noi'ssued by the board of heal SigneL...'a kZ....... (00 ...A ....... ...................................................... ............................... Date Application Approved By................. .................................. sr Date Application Disapproved for the following reasons:................. .............................................................................................. ........................................................................................................................................................................................................ Date Permit No. f .. Issued.... . ......... ......................... .................................. ----------- THE COMMONWEALTH OF MASSACHUSETTS BOARD—OF HEALTH ..........................................OF............................ ............................................... TwWrtifiratr of Tom pliattre THR I TO CERTIFY, That the Inci vidual Se age Disposal System constructed or Repaired by.................... .............................................................................................................................. .......................I C --------------- at.....................4_q]............................ .................................................................................................. has been installed in accordance with the provisions of TITIE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.......-------------- ....... dated_....__........................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM-WILL FUNF310N, SATIgACTORY. _ - L 12)DATE.......1?�:........ .........T1.25.................................... Inspector t. ............................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD� , FF HEALTH W..........OF............... ................................................................... NO.... ............A_ FEE...:;Lp.. ... Disposo Worho Cron r tin anti . Permission is hereby granted------. ...... .V.'a ........ to ........................... Construct or Repair—f-v4),ajj Individual Se Disposal System at No................. ...................... I at."A.......................... . ...... ... .................................................................................. Street A0 ., Z�.� Dated......1 as shown on the application for Disposal Works Construction Permit No�.A-- -_ ------ .............?.......... ...................................... .................................................. Board of Health DATE...........*..................................................................... FORM 1255 HOBBS & WARREN. INC., PUBLISHERS