HomeMy WebLinkAbout0027 JANICE LANE - Health (2) a� s J
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD qF HEA' -FL-1
...............OF........X'"",
Application is hereby made for a Permit to Construct (&-/) or Repair an Individual Sewage Disposal
System at -*- 3d
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Address Lot No
I 'F Owl r Ad ess *is.,
Installer Address
Type of Building Size Lot-/d./_1403......Sq. feet
Dwelling—No. of Bedrooms ..............3-------Expansion Attic Garbage Grinder
Other—Type of Building _Y;/
Other fixtures &i R"'k ---------
Seepage Pit No--------------------- Diameter.................... Depth below irJot_-_------ Total leaching area------------------sq. 6.
Z Other Distribution box (Y-4- Dosing tank ( )
~~ Percolation Test Results Performed 6y-------------------------------------------------------------------------- Date--_—.—__----_—.-
�
Test Pit No. l----------------minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
rXq Test Pit No. 2................minutes per inch Depth of Icat Pit.—_----_- Depth to ground water_--.—_-_—.�
�j ------_ ___----_--_—'-_----_-_—.-
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----_---'_.--------._---_-___—_.-__----_--_-_—_.—__--__. ---------------
---------------------------
U Nature o6 Repairs or Alterations--Answer when ......!t------------------------------------------------------------------- -------------------
--------------------------------------------------------------------------------------------- -----'------------`---'------------
Agrocozcor: �
The undersigned agrees to install the xforedeocribc6 Individual Sewage Disposal System in accordance with �
the provisions of Article XI of the State Sanitary Codc—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has
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��y�utmu By. '�-�-'���� ____________ ____________.___
Date
Application,Disapproved for the following reasons:--'------------_-__-----------_.-----_-----------
-'-----'------.............................................................................................................................................................................
Date
Permit No......................................................... Iaooel___��__�_"�~��
} w ` Date'- �-~��------ |
THE COMMONWEALTH.OF MASSACHUSETT_S
BOARD �F HEALT M
Appliratioll fox Disposal sal arks C onfitrur$ion famit
Application is hereby made for a Permit to Construct (,-/) or Repair ( ) an Individual Sewage,Disposal
System ate,
•
--------------=✓° . ------------------------------- -------------------- --......-------------......._....---•--------------------------------
/ Location/Address j 6or Lot No.
k.
Ow er
W ---------•=--. �...n /�... --------------- Address �J
14 Installer Address
Q Type of Building ,' } Size Lot_/lf j_:,1 .._.__Sq. feet
l/t-a-0 !Other—Type of Bedrooms
Gam- •---Expansion Attic ( ) Garbage Grinder (
a Dwelling No. of Bedrooms_____ ____._ • o. of ersous__.__. ___ Showers Cafeteria
Other fixtures l l •.._._ Z1hS�E.__.__ �?1t2� __.........
t 4-0-1---r , y"- -- -__--•---------------------------•-
d -
Design Flow_______________.�-7 .................gallons per person e c�ay. Total dall flow__.____________ •._O�_____---------gallons.
W t o ��
W Septic Tank—Liquid capacity�l�Z __gallons Leneth__ 2.-______ Width.__ _ _.___ Diameter-.____ _ _ _ Depth
i -- -
W Disposal Trench—No. ......Z........... Width___�._;7�______ Total Length........-R& -. Total leaching area,. f%'Q_......sq. ft.
Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area------------------sq. f.t.
Z Other Distribution box,(�44 Dosing tank ( )
Percolation Test Results Performed by__________________________________________________________________________ Date........................................
W
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____________________ Depth to ground water_____________________._.
W ................................ -- ...................
- - -•-••- _.
0 Description of Soil-----------•-••--••••••-•••--• �
•••----------------------- - - --- - - - -----••-- ----- -------•-------- -------
U ------•--••----------------•-------------------•-----•---•-•--------•------------•---------------•---------•-----•------------------•-•-----------•---•---•--•------------•----•-•••-•-------••--__---.
W
--------------------------------
V 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 issued by th oard o,health.
�. ..
• Date
Application Approved By. % --•------....... -----------------------------
Date
Application Disapproved for the following reasons:............................................................................................................
..---•-•----•---•---•---------••^----•--------------•...-------•--•-•-------------------••--•------------•--•------------------------•------------------- ------------ ---•------------•-•--------•---
Date
Permit No.........................................................
------------------------------- Issued.-q--- ��-- /-Z --.:.. �
Date
THE COMMONWEALTH OF MASSACHUSETTS
r BOARD OF HEM -rLJ
..............:..OF :.....:.................. ...................
�rrtifiratf of Tom phatta
T IS IS TO TAP at the Individ Sewage Disposal S em co tructed or Repaired ( )
by. - � -
/
i Installer
at --------------------- - ••...•--•- -- -- - -=_�-�'2-� -__-----------' ` ------------------------------------------------•---------•-•-----------=-------
has been installed in ccordance with,the provisions of Article XI of yThe State Sanitary Code as de `cribed in the
application for Disposal Works Construct ion Permit Na,
application dated.
��`�_ �_ �_ ._.__________._
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A G6lARANTEE THAT THE
SYSTEM WW�LL FUNCTION SATISFACTORY.
'•',�' ,r ...•ter DATE------- -- -------------- Inspector- -kjo------ -- P
_ •k x .r .!
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
. 't...............of::. ... ' '. .. '--- •------------- ...............
FEE ,
Digpo Nor ^ 4C ion anti#
PermissionI --:!E.-J--1V.. ...........
,:;is e01
reb granted___
---------•--••••----...-----
to Con. or pair ( an Individ ewage Disp`s System e r
at N �- - �_
treet .,,�/
as shown on the application for Disposal Works Construction P rmit N ___________________ DatedS. /-,fir ..�, __:._.:___._____
• •- -•--..._
y �y C -- oar of ea
DATE "/ - ...........
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ,r"'