HomeMy WebLinkAbout0140 PRINCE HINCKLEY ROAD - Health 140 Prince Hinckley Road
Centerville
A = 172 -201 - 128A
LO . AT ION SEWAGE PERMIT NO.
VILL GE
I N S T A LLER'S NAME & ADDRESS
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BUILDER OR OWNER
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DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
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No..-•--••..•••. Fiz$....... ..........
1 ` THE COMMONWEALTH OF MASSACHUSETTS
IA �q` BOARD - HEA
1
1 •:..---OF......... .................... ..... - -
T
AVVtirtttion "for Miivoiiat Workii Tomitrnrtion Vrruid.
Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Syst t p �kt /
..... ..._ __"r ...... -_---•--• ................ ....................................
n-Address ---or2-
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caner ( A
a .......... -•-- ••. •-- . .... ----- =................... --•-- ------•............----•---- •--......----- ................... ..........................
Installer Address �
Q Type of uilding Size Lot_.... __..�___./- ►-____Sq. feet
U Dwelling—No. of Bedrooms------------- Attic ( ) arb-,/ge Grinder VV Z)
p-, Other—Type of Building ----------__________________ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Oth r tures'.-F-_--o�.--------------------------------------------
w Desi n Flow....... ....... S. Mons per et-son per day. Total daily flow..._.
g .• P P P Y• Y ................gallons.
WSeptic Tank—Liquid capacity lions Length---------------- Width................ Diameter_..-__ . . Deptli..----_-_.-._..
x Disposal Trench—No; ______________ Widt,�i ------- Total Length.................... Total leaching area-_--...__---_---_-_sq. ft.
Seepage Pit No..... .............. Diameter.___4v__--___------ Depth below inlet.-.--____ ------- Total leaching area.._..__-_---__-_sq. ft.
.Z Other Distribution box ( ) Dosing tank ( 449- /�c « ' X 7- 7
Percolation Test Results Performed by..___ W�._ .'?.'L_... .......... Date..: ........
h Dept of Test Pit_..____.._________.. Depth to ground water..._.__.__.__.._.__.___.Test Pit No. 1................minutes per inc
P:4 Test Pit No. 2................minutes per inch Depth of Test Pit-----------_-------- Depth to ground water------------------------
-------------------
--- --- - ----- ---
, ------
x -------'-------�ODescri Description of Soil------------ � ----
4.------------------- -----c
w
UNature 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 undersign urther agrees not to place the system in
operation until a Certificate of Compliance has been 'ss by thard 5Khealth.
Signe .. . -
Date
Application Approved BY-----� . s j..................................
Date
Application Disapproved for the following reasons------------------------------------------------------------------------------------------------•---------•......
--------------------------------------------------------------------------------------------------------•--•••-•----•---•------------------------------------------------------------------------------
a Date
PermitNo........................................................7 Issued..... � ...../'�-----------------•-----------
Date J
J
-41 Ls
..V..
THE COMMONWEALTH OF MASSACHUSETTS
,,, ... BOARD HEAL- H
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, �.
Appliratiou -for Biquatial Workii Tonstrurtion Vaniit
Application is hereby"made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
y�.e
+� Lo ion = - or Lot No.,.
.......... t
;
= -/z. •. -------------------------------
- -
owner
Address
Installer Address .r
Type of . uilding - Size Lot.... . -... ---._Sq. feet
Dwelling—No. of Bedrooms-------------- -----------------------Expansion Attic ( ) Garbage Grinder ( !�
aOther—Type of Building ---------------------------- No. of persons_..__._...._-..__-_-------- Showers ( ) — Cafeteria ( )
d Other.'fies,,-�"'---------------------------------------------...............................................................................................
W Design Flow....... . tur
..... :4,).__.__.._.�f___..gallons per person per day. Total daily flow------�_.._. ..... .........gallons.
Septic Tank—Liquid capacity allons Length-----------_-- Width................ Diameter-----------..... Depth---...- --------
xDisposal Trench—No...--:----........... Widd-i---------n-------- Total Length-------------------- Total leaching area----- -..._..._._._sq. fI.
Seepage Pit No .e<�....__ Diameter-__-_. .' Depth below inlet_______t
___ Total leaching area...............-._sq. It.
z Other Distribution box ( ) Dosing tank ( � �'
-9 - '7�
Percolation Test Results Performed by------ ._-.-.-_ � ....__._ Date_._j.r -'"- .. '".r '.... ..
Test Pit No. 1..........•-----minutes per inch Dept of "Pest Pit.................... Depth to ground water......-.__.--------_
(_, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water---.---------- ---------
a' •• --- -- -
D Description of Soil------------(',t , " f -7
_. �__
- -•----------•-- -----
w
-------------------- �.
r - --- --------------------- ------- ----- -
x ----------------------------------------••--------------------------------------------------------------------------------------------------------------•---------------------•-------------------------
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 ffurther agrees not to place the system in
operation until a Certificate of`Compliance has been }ss d by the board of;health.
Si .. e sr r` .------•-----
`
r �• � .gne Date
Application Approved BY 3* ':
--------------
Date
Application Disapproved for the following reasons-------------------------------------------------------------------------------------- ---------•---------
----•---•-----------•-••-•--•---•----------•-----••••---------•-=--=----•-----•--•--•------••------••••'..--•--••----------•---•••--•---•------------------•-----------=--------....•-------•--•--•-•---
Date
PermitNo.......................................................... Issued---------------------- --------------------•---'--•----
Date
.,THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF 'HEALTH
.........../.... te:":..........OF........ Qi1 ............................
V.1rrtifiratr of 0.1-outpliaurr
THIS 'TO T F That the Indivitju_ Sewage Disposal System constructed ( or Repaired ( )
t
at
/ 1 stallerj /J / `f��r ..-•- -----
has been installed in accordance with the provisions of I of The State Sanitary Code.-as described in the
-
application for`Disposal Works.Construction Permit No--- -------------�--_-----.-_- dated-..._.. .
THE I`ISSUANCE'OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ........ ---••-•-------. Inspector....................................................................................
i.
THE''OMMONWEALTH OF MASACHUSETTS
^ BOARD O HEALTH
No. A—
............ =r....... ........of........: -...----- ..:.::......................... .."
FEE !!if
0age _,a1.,.,,
Permission reby granted_._...` r... ------------••---•---------------------------------••---•------ •--
( ) stem
to Construct. r Rair Individuat No. !" : �. - ---------- ---•----
as shown on the application for Disposal Works Construction Per Dated .jnl--------------
d! . a -----------------------
oarHlth
-
DATE -----------------------------------------•-••-----==---------...:.
r
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS -
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