HomeMy WebLinkAbout0053 CHAPPAQUIDDICK ROAD - Health S3 Ckarp ;qvijicA Rd
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UPC 12934
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SUSTAINABLE
FORESTRY
INITIATIVE
Cw fW Fber Sourcing
LOCATION SEWAGE PERMIT NO.
S.3 6q,4 P P 1 qUr Pke Fw l 15/
VILLAGE
12,
_INSTALL R'S NAME & ADDRESS
B U I-L D E R OR OWN ER
(�NIAd 00 s^Ti� crlo,v
DATE PERMIT ISSUED
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DATE COMPLIANCE ISSUEDz�(
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LOECATION ` SEWAGE PERMIT NO.
VILLL�AGE
INSTALLER'S NAME & ADDRESS
B U I'L D 04 OR OWNER
DATE VPERMIT ISSUED
17 .
DAT E COMPLIANCE ISSUED � ���
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................. .. .................OF............................I......... ------- - -............ ....
Appliratinn -for UWpoml Worko Tnntrnrtinn Vrrmit
Application is hereby'made for a Permit to Construct ( ) or Repair (It_� an Individual Sewage Disposal
System at:
---•----...Locat" n Add ......................................•---or Lot No. .
Ow er, Addree�
Installer Addr
Type of Building Size Lot...---------------------Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures
WDesign Flow_________________�5_.d.__.._._...........gallons per person per day. Total daily flow............................................gallons.
W Septic Tank—Liquid capacity------------gallons Length---------------- Width................ Diameter---------------- Depth..--------------
x Disposal Trench— ,o. .................... Width.................... Total Length-------------------- Total leaching area---...--------------Sq. ft.
Seepage Pit No.1. ........... Diameter---------9-------- Depth below inlet.................... Total leaching area.,l_w .sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation 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__.____-__.---.-_-_....
r' -------- ---------------- -----------------------------•-----------•------------------------------•---------------------•-•--------------- .................
Descriptionof Soil --------------•---•--------_.------------------------------------------------------------------------------------------------..
x
W ---------- ------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------- Y;
U Nature of Repairs or Alterations—A=swPrw�rep appli le., ._-.-.-_................
�2 Ppa �J ----
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 board of health.
Signed.. •-------------------------------------------------------------------- --------------------------------
f Date
ApplicationApproved BY --------------------------------------------------- ----------------------------------------
Application Disapproved for tliefollowing reasons:... D---ate-------- --•---
----------•-•••-••----------------------------------------------•------------•-•--•--•-----------------------------------------------------------------------------------------------------------------
Date
PermitNo.......1.7G1.................................... Issued----------------------------------------••-----•-------
Date
No..!- Z F��..... GG
........ ...................
THE COMMONWEALTH OF MASSACHUSETTS
.ti
BOARD OF HEALTH
yi _.-...... .....OF................................................
i Appliration -for Ravwial Works Tongtrurtimu Vrrutii
Application is hereby'made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System aaatt
yN
e
i n . .......................................� -•---•---------------
Locat .-Add w or Lot No.
--------------------------------------------
a �:tc6'r 4
�. Installer Addre ' .
d Type of Building ,Size Lot �*- Sq. feet
Dwelling—No. of Bedrooms____ ____________________________ _Expansion Attic ( ) Garbake"Grinder ( )
a Other—Type of Building ____________________ p Showers, )✓'— Cafeteria ( )
-------. No. of persons -----------------•------•--
dOther fixtures -------------• ---------- ---------- ----------..------..--.-----------•----------------------------------
Design Flow..................or-?...................gallons per person per day' '1 otal daily flow----------------------------------------....gallons.
WSeptic T.. —Liquid capacity-----.------gallons Length________________ Width---------------- Diameter---------------- Depth._._____-.__-..'
x Disposal Trench— o. .................... Width._-------------------- Total Length! _.--.___,___-. Total leaching area.__. .._.. sq. ft.
Seepage Pit No.__! -.___...... Diameter,--------9 --_ Depth below inlet ................. Total leachil g are sc 1. ft.
Other Distribution box i-,,Dosirig tank "' r
Percolation Test Results Performed'bY ----••--------•-••----------------------------•--•------•-•----- Date-.--•----------•------------•-------_
Test Pit No. 1................minutes per inch Depth of 'Pest Pit................... Depth to ground water...____-_-____.-----.
�14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------
a ----••--•---------- -•-------•----••-•----•-•................................................------------••-•--------...
Descriptionof Soil --•------•---------•------------------•---•---•--•-----------••--------•..------•----•---------•----------------•------•---.:---
x
U --------------------------------------------------------- --------------......-------------------------------------------------------------------------------------------;------------...
---------------------------------------
----- --=- --- --- ----- ----------------- -----
---------------------------------------------------
V Nature of Re a'rs or Alterations Answ.r wh applicable
-.' j' --+- ,. G. .;- �"," � -- -------- ------
t
Agreement: sk"*`�, •r
The undersigned agrees to install the aforedescribed Ih"dividual.,Sewage`kDisposal System in accordance with
the provisions of Article NI of the State Sanitary Code T1ie'imdersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued `the board o lealth.
.... Signed.-• •-
-•--------•----------•- ...............................
Date
Application Approved By ----- ............................
--------------------------------------------
Application Disapproved. or the Date
PP PP f following, :_._.__..____
....................................... _____.__.._. ------
---------------____-.--- ._-._. _______ S r y -
Permit No f--{
.. Issued ....... ate
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
... .. . .. .. .
Tat f irate of Tout Raw r
THIS IS TO CERTIFY,FThat the Individual Sewage Disposal System constructed ( ) or Repaired ( )
byYID .....f4��........................................................
F- .n r. - Insllr � � �`�.
at
has been installed in cords c wit the/pro i's'ons of Article XI of The State Sanitary Code as described-in the
application for Disposal'WortfsCon,s;truction Permit dated ..__ --- _ .x_..__
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
7, ,t...... Inspector w,
r .. ..£y"rC`%*w*•« '3.`,1F��t,y. .z*v.�DM:u^. Rr�r.V? +;i~r �+. y!'-apt j�', -V - •_ _, � .. r, ..
THE COMMONWEALTH OF MASSACHUSETTS J
BOARD OFF-Hs ALTH j
.........,............ .... ......... ......... ........
---..._.� - FEE...... r� E No. y�t „y
����#r�tr�i�ait
Permission is hereby granted---- -d_lrrL ---•-- .Ze.IVY4A---+----------- - ................. ........................
to Construct ( ) or Repair ( '�"'�n Individ al Se ag Disposal System
OOW
at No. L_.`t. w - t d�'' .1.... '" � �.I ✓ t✓-- __.__- ------ w�
°;i13i �'.'�`e m el.t 7_.--- Dated___. � '� ._ T
•�,.-. a <SF s 3t.nF .__-___ JAB. -�}•
as shown on�tlle application for Disposal V�orks Construclton ermit N`o. ,
......-•__---• - --- ........ .._•• .........
,d of Health
DATE......................................................................F�F
FORM 1255 HOBBS•& WARREN, INC.; PUBLISHERS
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