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HomeMy WebLinkAbout0053 PRINCE HINCKLEY ROAD - Health aVo.-•-••--......S F ............... THE COMMONWEALTH OF MASSACHUSETTS �.� BOARD OF HEALTH OF......... ..............:......................... Appliratiun -fur Riivoml Marks Tunitrurtiun Vrrniit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal systemW : - - f ocatron or- ddress LQt No. w _ ��,^ P✓ � Address a - = ------------•--•- -•-••-. ------ •---•--•-----.....-•-•-• •••--- Installer Address Q Type of Building Size Lot....l�a�.G -a...Sq. feet U Dwelling—No. of Bedrooms_______� -------------------------Expansion Attic ( ) Garbage Grinder per, Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) WOther fixtures ------ --------------------------------------------------_------------- ----------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity[ __gallons Length---------------- Width................ Diameter................ Depth.___-_-___--- x Disposal Trench—No.................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No--- _0.._...... Diameter..Q?7�?___- Depth below inlet____________________ Tota leac?�}lg area-------.----------sq. ft. z Other Distribution box ( ) Dosing tank G, v�✓l. aPercolation Test Results Performed by-------------------------------------------------------------------------- Date..........................._._-----_--. Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water--------._-_...__...___. rXq Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water............________.... .... L-­--- xDescription of Soil--- ---- ------....• . Q-- ; — ------ -----------------•-------------- c, �a --- --- ---------------------w �� - � '1� . L -----Ze--- r----------- ----*�--------------------------------- 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 NI of the State Sanitary Code— The undersigned fu -ther agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of h lth. tgn •-- ... --------------------------------------- ----------------------- Date Application Approved By.. ---- .... . ---- • -- � ' -- ---------•--------------- ( 0 Date Application Disapproved for the following reasons---..................--------•.................................................................-................ --------------------------•-•----------------•---•-------------•-•--.....------------------....----------------------...•-••----•.....-••-----•-•--•-----------•----------------------.....------•-••-•. Date PermitNo......................................................... Issued........................................................ Date S � S FIs THE COMMONWEALTH:OF MASSACHUSETTS BOARD OF HEALTH -- c- ./r .,/?-z-: OF......... ............a-c '.---. .......................... ,��s�lir�a�inn •fur �i.��u�ttl" lar�� Cnl�tt��rixrtinYt �rrn�it Application is hereby made for a Permit to Construct ( )` or Repair ( } an Individual Sewage Disposal System at* / // / .� / •tom,,.`-Location ; dr �.✓�--.(A .or.L�/.,."_ p-.._......--•--•........................ -----------------^--.._...................---•---•----. -. .--_------ --------. .----. {/^Owner . Address i2 -i{✓L'C.�._� .-------••----- -•---------� ---- ----L�-E.�ya��-���----•-------------------•--•--------- � Installer / Address 11 Type of Building ✓' Size Lot...-!�>-._e'I ram-_ -Sq. feet U Dwelling—No. of Bedrooms......... ,=�........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons_.--_--.-_---____----__--.- Showers ( ) — Cafeteria ( ) a' Other fixtures ---------------------------------- W Design Flow............................................gallons per person per day. Total daily flow......................................•-----gallons. WSeptic T;tuk—Liquid capacity_-----.._.gallons Length---------------- Width_-------------- Diameter---------------- Depth..._ _..._..... x 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 "Pest Pit...--.-.-----. De pth e t to -round water_..._.___.____...._... L14 Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water-----------.-------- ----------- :__ --------r ' } O Description of Soil--- r� �. - G= I rJ ..- 3 tl T�" p�� Qom```=/---=— ----- ------------ �,--- --- C� a� :n .,c.� ._ . - -- ' _ .J_ _.I_. �'-P _ � ' = -------------- ---_---- 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 \I 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 heJdlth. igne Date Application Approved By-------- r' ram, . .. ............. Date Application Disapproved for the following reasons:-------•------ --••---------------------------•••-----•------.-.-------•-------•-•-•-------Da----------------- ---------------------------------------------------------------------------------------------------------..-------------•------------- ----•-------------•--•--•- ------- .............................. Date PermitNo--------------------------------------------------------- Issued...................... --------------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD O�.l EALTH Lw/Ll ......O F............. G. ig? L .................................... err ifir ale of Tompliaurr TH S�) ., R 7S CET .yI That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) " by I , i �� Installer at ' -------- ----- /O Y - _.-�/------------- -- -••--••-- •------.-.---•-------- has ben installed in accordance with the provisions of :kr l 1I o The State Sanitary Code as described_yl t application for Disposal Works Construction Permit No.._ -_..1`_1 ------------- dated...-Q_. ----7--- ---- ------- ____. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE© AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE----..................... ----------------------------------- --=-------'----. inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS 76 BOARD OF HEALTH No.--------- ¢..T. FEE ------ ir g tti ns rurfijaat Trrinit Permission eby granted--- -------�-� to Construct,, or Repaiii an Indivic ial Sew a ispo Sy tem at ------- ---- ---- Street 7 �7 G as shown on the application for Disposal Works Construction Per iit- o.. ___ �Z__e,_e_t ed- �_­_ ---------------------- --------- _ - ................... Board of Health f DATE................................................................................ ` FORM 1255 HOBBS EN. INC.. PUBLISHERS 1 r & WARREN. ., v.,.•..�,::: .... ....... ._. _> ..,... ,.. _. I rIj Igo I�I �F M N P2ot�o�s�� 5�vr�.Acn� I— tDoo 6pAL. Le-7�ci4 1:,17- w+rH .�.Y. t rJ_`�i,_i•t L:,t�.: �-1:.1�t T'E.e..�/f LI.�_ �p`-�i 5 7FjA`- 't'l-I ej"ck4),.1 h ,,• rr 1. r �,���.'.' h',;'.4-iT'j OV- w .. Q UT n 1J Chi F '�,�_ ,"� l►I^:J� YZ> T1:�`t"E.L:+.��'�J�- !,: `�i �.I,. C�-►�1TLA �J 'SMQ �-�.� SAOL ( ) LOk_V , : , A S WAG E PERMIT NO. VILLAGE INS A LE 'S , DNA 7 & ADDRESS BUILDER OR 0WIN ER DATE PERMIT ISSUED ;q. � DAT E COMPLIANCE ISSUED L. 1 r