HomeMy WebLinkAbout0021 JANICE LANE - Health (2) a"1 to
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THE COMMONWEALTH .OF MASSACHr1SETTS
�\ BOAR® OF HEA TH
. pphrotion for Jispoa al Morkfi Tonfi#rnr#ion Vrrmft
Application is hereby made for a Permit to Construct (V/) or Repair ( ) an Individual Sewage Disposal
System at: -
cation- ddress or Lot
Own r dress
Installer Address
d Type of Building Size Lot,/0t__9?41------Sq. feet
Dwelling—No. of Bedroom�'_...j...... ...�--------Expansion Attic (X) Garbage Grinder ( )
Other—Type of Building _{t 4W..25 _.._No. of persons........_. __________ Sho ers ) — Cafeteria ( )
Other fixtures _ t ---...o..... 11? r ------------------
W Design Flow............................................gallons per person pey day. Total daily Pow--------------------------------------------gallons.
P; Septic Tank—Liquid capacity gallons LengthI ...... Width_-'i ' ____ Diameter_-_- ------- D th.�_�.._.
Disposal Trench—No. ....... ----------- Width....If'_._______ Total Length....;W...... 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.---__-__--_________-.-.
Test Pit No. 2................minutes per inch Depth of Test Pit---------_.......... Depth to ground water________--_______-_--.
a ------•------------------•-•---------------------•-=---••......------------•--••--•-•--------------•----------.............................................
0 Description of Soil----- ------------------------------------------------------•---•--•------------------------------------------------- -------------------------------------------
x
V -----------------------------------------------------------------------------•--------------------------------------------------------------------------------------------------------------------------
W
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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 i ued by the and h
Signed- X •-----•-- --•.............................
Application Approved BY = `C------= ......�C----'C ---------------------------- ----------------------------------------
Date
......•-•---•---
Application Disapprove y the following ye¢sons______________
€.._
" F Date
PermitNo _. �:_�a�............................. Issued........................................................
.,
-- -- - -- -- ---------- --- Date
" �.-. ppa�yy nn _ cf,�-•
No..... ......:............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/ ' 2., --....OF......
Apphrati n for Rspas' at VarkaToot utttjatt rrrntit �` {
Application is,hereby made for a Permit to Construct V- 1 or Repair ( ) an Individual Sewage Disposal .I
System at:
_�.►-
Location- ddress or Lot
Own r Address
-------------- -•-
Installer Address
UType of Building Size Lot1.()p...%_ _Q.......Sq. feet
Dwelling—No. of Bedrooms---------- !;;!C----j........Expansion Attic (x ) Garbage Grinder ( )
aOther—Type of Building _k_)62DJ5......../No. of persons..........e'_____________ Showers ) — Cafeteria ( )
Other fixtures (/} " r��'S Y , 1` �'XI4/----;--= �_4-----------------------------------------
W Design Flow................................_...........gallons per person per day. Total daily flow....................................-........gallons.
04 Tank—tic Se Liuid ca acit . L
W P q P Y���gallons �en�h
>��-Z-�---- Width::�.-�-/-- Dlclmeter-=""`-�----- Depth- •��=��--
x Disposal Trench—No......./____________ Width----/j..____.__.__ Total Length...:l_% ...... Total leaching area..._31_al9.....Sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area__-_.-______._____sq. ft.
Z Other Distribution box-("A) Dosing tank ( )
aPercolation Test Results Performed by--------------------------------------------------------------------•--- Date---------------------------------------
Test Pit No. 1________________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------------------------
P4 ` ---------------------------------------------------------------------------------------------------------------------------------------------------------•--
Descriptionof Soil........................................................................................................................................................................
x
W
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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 issued by the and of health.
t �
Signed. r' ..G �------------------- ------ .........l 7�✓"''
Date
Application Approved B -f --••--. - ?= t�_/___! -P
w ----------
APplieation Disapprovedf or the following reasons:--------•-•-----•---------------•-------•--•----•--------------................................................
-••--•--------------•------------------=•----•----------•--•----•-•------•-••----------•-•----------•--•------•---------_._...----------------------------------------------------•------.............
Date
I Permit No....... ' Issued.-----.:_ -----•---•-------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. . ... .. "..:Y'l` "-%" "fr<f.��.y.:r.:.....:..................................
watifiratr of Timpffiturr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System construct( ) or Repaired ( )
-by........f` �.. ,( r f ,N
= ,_r c r
";� �
installer
at ............... I-
--------------------- --•------------
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_________________________________________ 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
BOARDi OF,HEALTH�
.......7 ,
f ... ,
---------------
apaiial Works Tamitrurftlt tt Pprutit .-
Permission is hereby granted ./`; -•----•-•-------------------•---..------------------.....--------._._..-----..__...---•--------...............
'
to Construct ( ) or, Repair, ( ) an Individual Sewage Disposal System
at No.
Street
as shown on the application for Disposal Works Construction Permit No--------------------- Dated-----------------------------------_........
--------••----•--•------------•---------------------` ........................................
Board of Health
DATE =----------------------------•
FORM 1255 HOBBS & WARREN, INC:. PUBLISHERS -