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HomeMy WebLinkAbout0201 CAP'N CROSBY ROAD - Health (2) Zol CAPT Crosby c-enter Jae 193 - 16y S M E A D KEEPING YOU ORGANIZED No. 12534 2-153LOR FORESTRYY MIN.RECYCLED INTMTNE CONTENT10%® Certified Fiber Sourcing POST-CONSUMER www.sriprogramurg SR41290 MADE IN USA G1;T ARGA VED AT SMWO M � I f LOCATION �,� SEWAGE PERMIT NO. VILLAGE INSTA LLER'S NAME & ADDRESS BUILDER OR OWNER s �... n DA T E PERMIT 'ISSUED _ 7 k DAT E COMPLIANCE ISSUED _2 -7f 6 211al . 4 I No&,?' Fis......s.>.............. THE COMMONWEALTH OF MASSACHUSETTS r� BOAR® OF HEALTH (...� ...'...... .....O F.... ........................................ Appliration for Uhipwial Vurkfi Tomitrnrtion rantit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ' lr��/ 1.. ... .............. ....-••-........_..N . .. ................. .----- ` ---------------------------......--------.... Locat' Address - or Lot No. .........l. :S!`:_.Tll.. � � _--S/ ............ ............................... Address ................. ... i�r� s . .�1 ......d........----................................................ Ins ller Address Type of Building Size Lot._l ---14.�7----Sq. feet a Dwelling—No. of Bedrooms..............C� ...''_tt.................Expansion Attic (1V Garbage Grinder (Nd aOther—Type of Building _C _*Cl� !N7 No. of persons....3................... Showers (a) — Cafeteria (A14 Otherfixtures ----.-- .......................................... --...------------------------------------------------------------.....-----•-----..----- W Design Flow...........lf_0......................gallons per person per day. Total dail� flow---_--,��d....._T..................gallons. WSeptic Tank—Liquid capacit/ ..gallons Length.. -�."Width...,f.___...._ Diameter----S._..... Depth._s__'_Y._....... x Disposal Trench—N o.X............... Width. ............... Total Length........... Total leaching area....................sq. ft. --- Diameter.._... Depth below inlet.. L..._........ Total leaching area-•A�.... sq. ft. Seepage Pit No ----------- ------------ -- �_... z Other Distribution box Dosing tank Percolation Test Results Performed by.__---_�Qd!�/9.1Q�....��� ----__----- Date.--- .---------- il... ,a Test Pit No. 1........ ....minutes per inch Depth of Test Pit..��_.._____. Depth to ground water.._11lQ.rXZ_.... r14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �+ -----------Z----------------------- ------------------------ ----------.-..-.------------- -... .... •---------------------------------------------------- O Description of Soil------.Q `- � `� ---------------- v --------------------------- -------------------------------------------------------------- UW -------------------------------------W-Q'---'1S6---------- --------------------------------------------------------------------------------. Nature of Repairs or Alterations—Ans er when applicable............................................................................................... ------•--.----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iI'A 1E y g g p . y 5 of the State Sanitary Code—The undersigned further agrees not to lace the system in operation until a Certificate of Compliance has been issued by th7 bbpard of health. Sig ! 2J...... ---- -------------------•--------- `F............... ye Application Approved BY i ....... ...................... ~/ 72): - Date Application Disapproved for the following reasons------------------------------------------------------------------------------------------- ----------•-•...._ ---------------------------------------------------------•--------------.....--------------------------•-------------------------------------------------------......-----------....----------••---•--. Date PermitNo......................................................... Issued....................................................... Date THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA THE COMMONWEALTH OF MASSACHUSETTS r BOAR® OF HEALTH ... Y?.................OF... fP P i E= 1 t f �l_C -----------------........................ 1 Appliratinn for Dispao al Workg Tnngtrurtinn Prrutit Application'is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .............. - ..._..... ...... .....-•-....................---........................ ......--••--•--...----- P Location-Address{' y �r-A, or Lot No. ............... .'Own r.-----••-•_•_._-•----•----•----•-•'f----- .........._.._.._.__._.....--•----•---•....' ......-_-_..._.-----....--------.^•----.._ Address a . 1 ;t. .. / 1.... .: ./ -•----•-•-•....................•--....... ...........................�J'!tr-..F-;.�---.....:...--•-----------................................ ... ---- Installer Address Q Type of Building Size Lot_._��.... _.-7-----Sq. feet U Dwelling—No. of Bedrooms.............;'_*...........................Expansion Attic (4' c) Garbage Grinder (n'�) aOther—Type of Building No. of persons__.J___________________ Showers (C', — Cafeteria (Ae.) QOther fixtures ------------------------------------=----------------------------------------------------------------------------------------------•----...---....... W Design Flow...........!.Lo........................gallons per person per day. Total daily flow...... ._:_ ___.___..................gallons. WSeptic Tank—Liquid capacity ...gallons Length._...`!,.-."Width-_-1 �`....__ Diameter_____ ________ Depth................ x Disposal Trench—No.,,!'................. Width...`............... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.....f._.--__-•--_- Depth below inlet.._.:............. Total leaching area.?�..��._._._.sq. ft. Z Other Distribution box ,V Dosing tank -Peercolation Test Results Performed by......!_.!"::'L:!! .............',(!...�(...................... Date.......:'............................... a Test Pit No. 1.......... .....minutes per inch Depth of Test Pit._/_._C.._....... Depth to ground water... ...... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ----------------------------------------------------------•---•--•-------•-•- -----------------------------------.--------- --------- 0 Description of Soil...... .... .....--•••-•. ........................•---••-•-------------------------------------. _---------------------------•--. ..........---- U ...................................................... --•--• .1 . t 4,1-- -- (------`-` t` f ---•------------------------------•.r--•---•---••-----.---...---- --=f ....,< .._.=..^.!i_ !... ---......-----...------------------------....._...------......----------............. 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 iITL✓ 5 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. + Sig !�``..•.' Yf ' t r{ �. s o Application Approved By........ � . 1 .. ` --- •-•-- Date Application Disapproved for the following reasons______________________ --•-•------•-••--------•................•...........•................ ------......-- ......----•----------•-----------•----------•-----...----•------------------•---------•---•-•-------...----••-•••••-•-•......._..••....-••-•-----•---------•-••-•-•-•--• .............................. j Date PermitNo......................................................... Issued-....................................................... . ' Date R THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH /` ......................OF... .......... } TprtifirFatr of Tilutlift aatrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( , or Repaired ( ) /� e f t /f. /•/' , r1 Is !` r - !f •/ t7 /�Lr stall( r �f Cyr I rt l-Cr( t1L( at.--= ........................................... -- -------------------------------------------•-- ---------------------- -------• --. has been installed in accordance with the provisions of T ` The State Sanitary C.de as des m the ------------- application for Disposal Works Construction Permit NO—',� -____-✓__..� .............. dated-__.._ ------------------------- THE ..__,,. .:. ISSUANCE OF THIS CERTIFICATE SHALL NOT EEtONSTRUE® AS A GUARANTEE THAT THE - SYSTEM WILL FUNCTION SATISFACTORY. DATE..........�!-""---•�'"�----�="----���.................................... *' Inspector--•- ----=---------�'![_ >�•--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH J �7�` (• i T,t. ..............OF...!. .�;.... .................._.......:.... N /.,. FEE.. / --�.............. tla �a1 � � �aaatr�trin rr�tt,ry _ Permission is hereby granted...__ __. /t _..f_ '_l r .................... ................ r to Construct O or Repa'Ir (, ) an Individual Sewage Disposal System f at No.... t i t "+ i':7 li �� - t f /�. ............ `- <"I._.< P �- l�fl<- .:< t ..,.. Street as shown on the application for Disposal Works Construction Per it o.......... ... ... �t d____ " ....... ,. =.................... --• �� �':Tea -- Boar of ealth FORM 1255 HOBBS & WARREN. INC., PUBLISHERS •,- �:';V L c�7- 8 L o i No j3.N1. /s /-/YD � 7�ST /yDGES , 2!1 tt ------ iio 92 . /aa. 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