HomeMy WebLinkAbout0467 PRINCE HINCKLEY ROAD - Health 6� OR-O-s
... ................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD QZFHEALTH
45
�.D4---------------0 F........... ................... ................................
Allpfiration for Disposal Works Tonstrurtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
/(!!�j
.... at: ......_• ........•-•- --•.............aZk�
.._..............................
ocation-Ad ss IN
......--- ... wn Address
WW1 •............. ........ .•--....... - .... ........................................... --•-••-•----... ....
� Installer Address —
d Type of Building Size Lot.._�_5�_ a_._Sq. fee
U Dwelling—No. of Bedrooms......�.............................Expansion AttiCaw�d Garbage Grinder
Other—T e of BuildingNo. of ersons..............._------- ers — Cafeteria
Othe; fixture.---------------------------------------------------------------•--------------------------...--------- -------
-- - -------
W Design Flow_________ ____ _`�7________________-_gallons per person per day. Total daily flow............. _____ ..................gallons.
WSeptic Tank—Liquid capacity/)"Olgallons Length................ Width................ Diameter................ Depth................
xDisposal 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........................................
aTest 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........................
�+ ---•--------------------------------••--••-•----•-••------•-•-----•---------.......---•-•---------...........--•------.......-----•----...........•--••.._...
0 Description of Soil........................................................................................................................................................................
x
U ----------------•-•--•-•--•---------------•---••-•-•--•----------------------------••--••-•--•------------•--------•----•--...-------------------•--•---•-------------•---•••---•-----•-----•-•---------
w
x •------------------------- .............................................................................................................................................................................
UNature of Repairs or Alterations—Answer when applicable........................................__._____._.__._..__.._..........____.__....__--_-__-___.
Agr nt
T e undersigned a rees t install the aforedescribed Individual Sewage Disposal System in accordance with
e 'sion State Sanitary Code—The undersigned further agrees not to place the system in
o r "io til a ompliance has been is e by the b health.
Si ned--- --- --- •--...--•. ..... ........... .............. `/`G �._../ � I—
Date
Aation Approved By.....---- . .. --- .... ................................. --------1-1- -7- .._..
Date
Application Disapproved for t following reasons-------------------------------------•---•-------......-•------------------------..:_...----. -•-----•-••-------
-••--•----•----------•----•-••----------------------------------••--••--••--••------•------._............._
Date
PermitNo......................................................... Issued_.......................................................
Date
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I M ^C&L
DATA
No......................... FBIa..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......... 11 -, OF..........,f.':-' f �. • �< <'�
Applirtttiun for Disposal Works Tonstrurtiun thrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: a f'
......... '- . ............................................... ....- ......................--......----•..............................................................
Location-Address i f' or Lot Nb'r'
Owner-' ) f Address -
r . ... �•.,.. . r . .�..._......
Installer Address —
UType of Building Size. Lot......f-'-!e::...........Sq. feet
I-, Dwelling—No. of Bedrooms.......=::................................Expansion Attic";(Ki ,l/ Garbage Grinder
aOther—Type of Building ............................ No. of persons.......................--_.. Showers ( ) — Cafeteria
d Other fixtures ---------------------------
------ --------------------------
• --F`z-.
---
W Design Flow____.__'.='... .`.:%...................gallonsvper person per day. Total daily flow......................._...........................gallons.
W Septic Tank—Liquid capacity_.__ gallons I:ength................ Width................ Diameter-______---.__-__ Depth................
Disposal Trench—No. .................... Widtfi3.-.._:__.-:__._..I Total Length.................... Total leaching area....................sq. ft.
x ia.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
~" Percolation Test Results. Performed by-_ ......_._ Dates__.........................................
Test Pit No. I'____..•_-__-_-minutes per inch Depth of Test Pit.................... Depth to ground water.___--.____-_-__-----__-
fT.f Test Pit No. 2........:.......minutes per inch Depth of Test Pit.................... Depth.to ground water........................
W
Descriptionof Soil....................-....................................................................................... ..- ••• •---•-----••..........._..
x s
W - .,
UNature of Repairs or Alterations—Answer when applicable....................................................
------------... :._.._...____..___.__....___.
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•----
Agr nt: ..,
T e undersigned agrees t install the aforedescribed Individual Sewage DisposalY System in accordance with
e sion �' e State Sanitary Code—The undersigned further agrees not,to place the system in s
o r.tio 'til a Compliance has been issued by the board of Health .�
Signed `�
ate
A p' ation Approved BY !i` (� .. ---------•-----------------------•--------- ........d... .... ...
Date
Application Disapproved for t following reasons:.....................................................................------------------------------------------
---------------------------------------------------•---------....-----------------.......--•-------.....•.....--------...-•------------------------------------------------------------------------_-.---
Date
PermitNo......................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
%BOARD OF HEALTH
...OF.....................................................................................
f�rrtif irttte uf��(�unt�rlittnre .
THIS IS TO CERT ' Tat tU Individual Sewage Disposal System constructed ( ) or Repaired ( )
by--------------------_------
T'� -C !(f2,
--- - --
at _� 1 t h I sca
-••••-•-----••-ce
has been installed in accordance with the provisions of TIT d j of The State Sanitary Code as scribed in the
application for Disposal Works Construction Permit No....A__��..�.._-.toa� "'"
--------.••.. dated__... �___'17- - lr..-----------------•
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM°WILL FUNCTION SATISFd- TORY.
DATE...........-•--� � .. Inspector. ._
THE COMMONWEALTH OF MASSACHUSETTS
S �
BOARD 'HENOF...... ...........................�:.................._.......................
No......................... FEE.........................
r n�VWrit
Permission is hereby granted_-- `
-•-•- --•-•--••---. •................•---•--•----....••-•--••••••-----••--•••-•••---•--••---•••••----....---............--••••..---•-
to Constr t or epair ( n-In 'vi 1 Se e A.-O
ystem
s'�
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
-------------------------------------------------------------------------------•-••.---•--••-••-..•--•-
Board of Health
DATE ....... ------•.
FORM 1255 A. M. SULKIN, INC.. BOSTON
S �7 .,3....gCu.(Zooly
b
04,1C.Y t=CoW ri. :. ll�S� i� 3 3`o G. P. D.
Sep! It-' -rA(,jK - 53o 1, 1507, * 4q5 G.
D nsAL; P.�T_; �sE 17
5-1 DEV�li�1U�..'-kfZEA 15o S. P. °
Two :; :: 2.,...5.: . BTr P. DIs
.
¢oPT
To TA lL P GS I G Q - 4 ZS' o-. P. D.
TOTAL: DAILY FLoW s 330 G.P,O. T;1"Y 18
. : ti
PET Goo TON P-AT III +rJ 2 M►N o2
� I
-M t t"Y"Q 1.1 GG.�"...•. ; _ �,v k ,.tit \ '�
CK
OC
rd FG• -O FG
/000
oisr.
r . BOX
o• P•T '•" An/,
V� o I%��I '► �19,Z 4�, G'E.2T/F/EO PG OT pL:4i✓
. W-4sHC--D '.
O .• ..
Eti T L 4L M .
9-2 5/-8 5
PRo ILL pLQiV IAZE1 EIez I
No ScALCLUZ,
,I
kA
77zlW •T-7/E . ,,a;,.�. ;!; '"y D.F.f .Sf/aW.V 1 � 8, oe�A
/�E•�Eo:v G�i+lP�Y�S (,r//J'�TiyE.S/OE,[,/NE B.dXT�.2��t/YE /it/G.
AiVl,.SEr,,YAGv .e�4V/2ENI�NTS O� Ti`/� i2EG/ST�P�I.GQNI�.S!/.e!/��yo,P,s
.�.vl,7 /S it/OT" GrST�.2Y/GGc a �1�5�
LOCQr�.o W/T.S�/y Tiy.E �LaoO.ol�4/ti.
v^' -•L�-t'`✓- I�'L.V t r! V���nCs` 'ti.,,,.-�,,.�'^••""a+ /� �t/ � T 1�.4SE0 aAv.4 A/
✓ram K/�h�E.e�aN S.�oU[.D�/pT l�.E USEpi
05
LOCATION � � /70 'SEWAGE PERMIT N0.
/67
ALI: 5
VILLAGE
INSTALLER'S NAME&(nADDRESS Q
� QP'�t�,7 ��y_��� 4� • mac_ -
�.� d
BUIIffiER OR OWNER
DATE PERMIT ISSUER
DATE COMPLIA CE ISSUED
��
�w��'^
Y��1� \r
3 , (<
� t
`�� 3�( �
�, .