HomeMy WebLinkAbout0014 JANICE LANE - Health (2) / \��
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No..........2..7.1 o4\ 4",
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
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10 6u.,el.. .. ......OF........... A/'� .5.' "$.�Li .......................
Appliration for Disposal Works Tonotrurtion Prrmit
Application is hereby made for a Permit to Construct (�or Repair ( ) an Individual Sewage Disposal
System a
oration- ddress or Lot No
.......... .. --•- ---�. -1 vua ------Ial......��W.✓?:`--
I Owne /l� j�.�d7l7drensso
...-t ���.................... v-y...SC�. .......
Installer Address �,,
d Type of Building Size: Lot__7%_at.1/......Sq. feet
Dwelling—No. of Bedrooms-------E;IZ_.. ----------
-_-S----------Expansion Attic'()() Garbage Grinder ( )
Other—Type T e of Building {1� .�.............. o. of persons.-_.. ....__. Showers� yp g p s�_____._._ ( ) Cafeteria ( )
d Other fixtures l l�° odeFi. �• �AG-, t sf,12 ..r . } ---- ••--------•-------••---....
W Design Flow___________________________________________gallons per person e day. Total d Pow............................................
W Septic Tank—Liquid capacity/eOPgallons Length-_-��. Width_. -_-- Diameter________________ De th__-.S'__Z....
i
x Disposal Trench—No. .....?�_._...._.... Width--_a�___________. Total Length---- .___.... Total leaching area...... 0.0....sq. ft.
Seepage Pit No..................... Diameter..............------ Depth below inlet.................... Total leaching area__-----_--__---__sq. ft.
Z Other Distribution box (X) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date-------------------------------------
a Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------
4-1 Test Pit No. 2................minutes per inch Depth of Test Pit____________________ Depth to ground water--_-_-_-_---_______-.---
a -•------------------------------•...._....•••--•-----...---•----•••----•--•--------•---•-----•-•---•.........................................................
Descriptionof Soil---------=-------------• -------------�--- •--•------•--•---- �------------- ' -F---
T----�--
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k g l - � -W - e. ------------ r/.-=- -----� ------ --- - -----------------------
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U Nature 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 ' sued by the oard o h lth.
Signed = 7 Z 7`3
-
����+ Dat
Application Approved Y '�� C= 11y---l---•------•-•--•---�-----------•----- y" �- 7
Date
Application Disapproved for the following reasons-----------------------•----•-----•-------------------------------------------•---------------------------------
---•--------••-----•••---•-----------------•-------•------•----•----------•----•----•••--•-•--------••-••-----•-•-------------------------... ---- ..... ---��---- -••-------------------
Date
PermitNo..... .................................. Issu --- ------------ ------ ----•- -- •. ----
Date �+�
y ` 5 J• -.y7 (. "" yew- i' xq" i� .ew^
No......................... ..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................OF...........
.�/�.d. : .
Appliration for Bispooa1 Workii Tonstrurtiun Permit
Application is hereby made for a Permit to Construct (V ) or Repair ( ) an Individual Sewage Disposal
System a
o ------.....
Location• ddress ✓ or Lot N
d
o
OwneC (°� ress
a �ih• /r�C Sz i�r1 ry'] C:}.P. . ------
�a • , ;�/2141t.C..
. --
Installer Address
Q Type of Building Size Lot._79.42..,K-------Sq. feet
U Dwelling—No. of Bedrooms.________ ��7°..:S...__....Expansion Attic (X) Garbage Grinder ( )
114 Other—Type of Building O__C>l G............... o. of ersolis.__. _-_----------- Showers Cafeteria ( )
a' Other fixtures ��,, / 49
0:6 -=-----CAR 5,----•-- F 1 . i t 2 ------r /A--------------------------------------------
Design Flow............................................gallons per person er day. Total dai y,flow----.-------..---------------------------- gallops.
WSeptic Tank—' Liquid capacity/0AV.gallons �e�gth..24*✓. 'Width__--___y_._... Diameter________________ De __--_.Disposal Trench—No. .... ............. VVidth_..�- .______- Total Length___a.�......_. Total leaching are.---- ft.
3 Seepage Pit No---------_--------- Diameter.................... Depth below inlet.................... Total leaching area------------------sq. ft.
z Other Distribution box ()(-) Dosing tank ( )
aPercolation Test Results Performed by....... -----••----•--•---••--•-••---•--•---••----•------•---------------- Date........................................
Test Pit No. 1................minutes per inch Depth of "Pest Pit.................... Depth to ground water_-_________-__________-.
t=, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water________________-_-___-.
W -------•----•---•-------•---•--•--•--------•--------•-------•------•---------•----•--------------------------•----.-. -- --•-••......••---
ODescription of S61:.---•------------------------•----------------.f.............. . -----.._._...-......•••---
o
W
---------------------------------------- ...............................................................................f.........................................................................
U Nature 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 bee 'ssued by the hoard of h lth.
/�, "
Signed_! . . ...... ..._....���-��%::-��1 ---=-- --- =--•- ---��_--
A lication Approved B G !'. ........... = ..._f �> Da
PP PP Y = 1 •-----------�,...... '
Date
Application Disapproved for the following reasons:---•---------------------------•--------..........-••------ ............................
Date
Permit No. �----------••---•---------•--•----•--- Issued.. ,
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
E
.............�fi. G�."..........OF...... .�'.'�r�-�
TertifirFatr of TompfiFanre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by---- �`=° ` 1.f! '"<1,` .".r e,_!'�
_ Installer.
at = f� ` �G` ---`--•---------•----•--•-------•-•---•--•-•---------------•---------•-•-----------...................
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.....A..7—-------------------- dated-------------------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISF CT R .
+.--� \`\ -•--- � ---- Inspector.....................................-............-.................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Dinpaii al Workii CnuaT trnrtiun Permit
Permission is hereby granted_.......Ae....-t--�_--••-4zl '- J'"1..--•-•-------•-----------•---••--------•--------•................•-----•------
to Construct ( 1() or Repair ( ) an Individual Sewage Disposal System
atNo. - ; >... ---•- ----------------•--- ••----------•-----------------••----------------
Street
as shown on the application for Disposal Works Construction Permit.No �_.�_>-____- Dated..........................................
--•-•--•--••---••------•-----•--••---••-------------••---------•---------•----•....--•-•----••-----_..._
Board of Health
DATE................................................................................
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FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ./•i ,.- f��X
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