HomeMy WebLinkAbout0061 PINEY POINT DRIVE - Health c
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KEEPING YOU ORGANIZED
No. 12534
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FOR SUSTAESMMRECYCLED
INITIATNE CONTENT 10%
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No......`a 5:... 3 FEB.•. ...........
THE COMMONWEALTH OF MASSACHUSETTS - -
BOAR® OF HEALTH
............. ....-------..... --••------......-.-•-----
ApplirFation for Ehipaii al Works Tnnitrnrtiun .eruat
Application is hereby made for a Permit to Construct (tiWor Repair (t-jr an Individual Sewage Disposal
System at: I I
..........(.I pine�P..�alrif ..1<Q4i..eevieu��Ie....... -----••--•---l�rnt,E--••---o�-----------•-------------•-----------'---�--..-..........----
I Location;Address L.
x� Lot No. f
...................................... ....�L �. P-----••---�-°°�---.CQ��C-P.dL,% .---.......--
Owner Address
W (wCitrxeo FYle_- _C°Q jmlmra'--�j° k!: 1.4.4 ---------------
a Instal r Address
dType of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons____________________________ Showers — Cafeteria
$14 Other fixtures __________________________________
W Design Flow________________________________............gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity.l6 __gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No_ ____________________ Width................... Total Length.................... 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........................
(i Test Pit No. 2................minutes per inch Depth of Test Pit____________________ Depth to ground water........................
_._..---•--------------------------•------------•-----------------------............•-----•--••-•-•--. ----•----•--•••----•-----•--••--••---•-----•----•-•--
0 Description of Soil........................................................................................................................................................................
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U ---------------•--••---••--------------•--•----------------•---•-•-•---•--------------------------------•----------------------------------------•------••--...........................................
----------------- ---------------------------------------------------------------------------------------------------..-,----"--.---...----------------------------------------•-----�,�,,-,----rr------- -------
UNature of Repairs or Alterations—Answer when applicable._._I?7 _it[tK..._I_ _-_'__r1. pa.glk� 4_ !.K+ 2L¢a.
......................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITI.,I 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.
Si .._-•----
,�,,^ Date
LApplication
plication Approved By.......................... ....C�_�_ &V._.\..._........_.......--•---... _..------•
Date
Disapproved for the followin easons_.........................___________________________________..........._........................................
.........................•---•---••---...._..---•--•----•-------------•-----------......-•-•---•-•------•-----------------•-•-----------------.....................................................
Date
PermitNo......................................................... Issued.......................................................
Date
�
Fxo.l ____
� THE COMMONWEALTH orMAssAo*ussrTs
BOARD OF HEALTH
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��pplirati�«� �� Uispoiial Works TonstrurtKon 11amit
Application is hereby made for Permit to Construct (,Q&-)-or Repair (4.°Tuu Individual Sewage Disposal
System at:
-__----------- ,--'-_-_' --'--'-----------'----_--_'--_'---__-__----__-- �
Location-Address
Lo
-- �� �
Owner Address
_---(��l���c�'����z�4_1�c�l_'_-_-'------'-'-_-- -� �lL-�l8-/��-��'-'
.�.. .���� w z=�K�' -' - ---Ad��s---r ....................
Iype of Size Lot-- Sq. feet
Dwelling--No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................'Showers ( ) -- Cafeteria ( )
Pw Other fixtures Design Flow.............................................gallons per person per day. Total daily flow............................................gallons.
ScpticIaok--Liquid' _gallons Length................ Width................ Diameter................ Depth................
Disposal Trench--No .................... Width.................... Total Length.................... Total leaching area----------uq. ft.
Seepage Pit No'--_--._- Diame1cr-'-----. Depth belmrioloc---------' Iotu leaching area..................sq. b.
Z Other Distribution box ( ) Dosing tank ( )
'- Percolation Test Results Performed by.......................................................................... Date........................................ �
Test Pit No. l................minutes per inch Depth of Test Pit.................... Depth tv ground water........................ �
�Xq Test Pit No. 3................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �
_ --_--_---''---_--_'__-__-----------'-'-'-_----'_-'-----_------_--'_-_--
��. ofSo�_-___-__---_-_-. -___.-_-___________________________________
---------------------------------------
---------------------------------------------------------------
_-------------------------------------------
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'-_-'-----.-
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Agreement:U Nature of Repairs or Alterations—Answer when applicable...-- 1.n....
~
� The undersigned agrees to install theafore6escribed Individual Sewage Disposal System in accordance with
� the provisions of TITLE 5 of the State Sanitary Code— The undersigned further ugreeu'oot to place the system in
operation oobl o Certificate of Compliance has been issued b the board of health
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L ,0 -CA TION 5Ew ir. E PE RM. iT No.
VILLAGE
; NSTA LI. ER'S M A M E A A D 0 A I S S
Ei U t L D E R 0R OWNER
_C � tl,4 e e Sys cvs
-
13ATE PERMIT ISSUED
OAT C 0 M P L ! A H C E ISSUED 10
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