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HomeMy WebLinkAbout0136 SHEAFFER ROAD - Health �I O S M E A KEEPING YOU ORGANIZED No. 12534 2-153LOR FOR AINABLE MIN.RECYCLED INITIATIVE CONTENT10%® Certitidfi ebers—ing POST-CONSUMER ww,vsn9rcgr qws SH O12M MADE W USA M ORGANM AT SMMI COY PSE013C L0CATJON / SEWAGE PERMIT NU. �e / 130 S'h�Pct er 1 .7 V I L L A C E -e r INSTA LLER'S NAME i ADDRESS rtL re h ,!; S U I L D E R OR WNER a,C.� r a�v d DATE PERMIT ISSUED — � DAT E COMPLIANCE ISSUED J 47 Ir :: No..k-.r�.:�.�31.. Fx$ d.:................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................. .SS .�...........OF.........� .. G G.XJ' -i.................................... Appliration for Biipnial Workii Tonotrnr#iun rumit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: . qt :.... .. 3 ......................... ation-Addr ss or Lot Q- ............ ...`I.(Q` ........... �. Q.��........... caner Address ............................................... ..•---•.....•--•-•--...•-•-•...------•----.........•..................- Installer Address 1. S oO� U Type of Building Size Lot.......-_..-N%..0...-...0 0 feet Dwelling—No. of Bedrooms........ ...............................Expansion Attic N-4 Garbage Grinder (h.o a`4 Other—Type of Building No. of persons............................ Showers g -.•.-.-...-•--------••--•--• P ( ) — Cafeteria ( ) dOther fixtures ---------------------------------------••------........-•---._...-•----....-----------------------------..........------......................•_•--•-- W Design Flow...............ULA.....................gallons per person per day. Total daily flow.._......33-la....._....................gallons. WSeptic Tank—Liquid capacity.OA-0—.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 ( ) •••• Date----••-� Percolation Test Results Performed by WC ....`t.�. (........................ . Test Pit No. 1...... ......minutes per inch Depth of Test Pit.................... Depth to ground water........................ fX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ C4 .............. .. •...........r ----•- ....... >...................... O Description of Soil �._ - . ....................: C,ttu G�.f.- .. Ux •-•--......--•---•-•---•-•••--••-•-•-••-•...---••-•-••••-•-•-•......_•-•••....--••-••••-•-------. ...............•--•-••-•---- .......................................................•............ 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 I ITI U 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be �issu(ejdoby the bo of health. / Signed.... -•-•C �-....L... ....... ...�.a'1.1.,�1.. . Application•Approved By................................................. , . - �� Date r ....---•••......•-•-...... ........................................ V Date Application Disapproved for the following reasons-------------•-------......_..---...------------------......---•----•-----------•--•--••••--........_.......... -•...................••-•-...........-•-••••••---••-•-•••••-••-••••••••••--•---•••••---••..................•••-••••----.........-•••--••-••---•--.....-••---••-•--••••-••=-•---•-•••-••••••--••••-••_.... Date PermitNo......................................................... Issued....................................................... Date d THE COMMONWEALTH OF MASSACHUSETTS - BOARD OF HEALTH ..OF............. .... ................................... ;��r�lirtt#i>xYt �nx �i��n�tt� nrk,� C�nn�#rnr#inn �ertni# Applicatiorijs hereby made for a'Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at ............. ... ----- . - ............ --• v 3 v ........................._.. �_ '(.� /� `anon-Addr ss ,/ f-�•--y/y or Lot.j.... ...•_.•••--,y J/(� •w-•--..._.�J.CJ¢ c5..:....1ar Slew.?. �: ......................... __.........0../. r4-.. .�Y-°�f7....... .. 0-.a-4--.._...... .._...... ... wnert, Address W _;__......:.....:............................... •..---•--.--•.- Installer Address v. Type of Building',,;,,`r=, Size Lot.....p .....Sq. feet Dwelling— ......... " ___....._Expansion Attic (� Garbage Grinder (1%o No. of Bedrooms ��'.. a� Other—Type of Building _____________ d p ng ............... No. of persons............................ Showers ( ) — Cafeteria ( ) Y Other fixtures _.. •-••------••--•-•........... ...... . . W Design Flow.:...... .....Vi_4?._____.._.__..__.____gallons per person per day. Total daily flow_._.:_..3. _0__________.___. __.gallons. tx r; Septic Tank—Liquid capacity:�0a0_.gallons Length ........ Widtti................. Diameter:_:_.__.__.____. Depth................ t W 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 ( ) aPercolation Test Results Performed by-____ [F ::�1`._:."�:�t�............................... Date..........a/�!.&_� .. .. . 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; ._.........-•----.....--- p Description of Soil 1 x ........... 3 . .L'-•-- C..u _ 5�.. nce . ................. • . •--•• -•--•- ------------------•.._.._.._..__.._.._......_.. ;. U . Nature of Repairs or Alterations—Answer when applicable________________________ ________ ...._._.__._.._. - f :r Agreement The,indersigned agrees to install the aforedescribed .Individual Sewage Disposal System in accordance,with the provisions of-TITLE 5 of,the State'Sanitary Code-.Ttie undersigned further agrees not to place,the system in op&ation:until,a Certificate of Compliance has be issued by the bz rd of healih. ur a : y Date Application Approved BY ............. ...._._. .......... Kw Date . Application Disapproved for the following reasons:-------•----------------•-- -----------•-----••_---------........---•-•......--•--•-- :.........--•- ---=-------------------------------------------------------------•-----------------------......--•-•-•---'---------._........-----•------ ------------------------------------------------------- bate PermitNo........................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS �. BOARD OF HEALTH ..........................OF............... ................................. ......................... (Irr#i€irtt#r of Zuntphattrr TH S IS„TO CERTIFY, T t the Individual Sewage Disposal System constructed ( �`®rRepair'ed ( ) b .. .. .. a n.....er has been installed in accordance with the provisions of T TLE 5 of The State Sanitary Code s ibed in the application for Disposal Works Construction Permit No.�.�._':.... ________________ dated. ' .o. .,..__._____._..__...._.._ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE it SYSTEM WILL FUNCTION SATISFACTORY. DATE............................•-------......--------...................•..._...... Inspector.................................................................................... rt THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH / .. ..... FEE.s.................... i �r�a �t1 nrk Tnno#rnr#ion "rrnti# Permission is reby granted-----..... ----------------••-------------------._.....---..._..--••-...............••-- to Construct_-( r, Repair , an dividu ewage.Disp sal System �- ------------- ------------------------- Street - - as shown on the application for Disposal Works Construction Permit No..................... Dated........................................... d "r r DATE..................................... /� Board of Health ------�J.J-- -!/ FORM 1255 A. M. SULKIN, INC., BOSTON t II �I►JG�L's FAM►►-Y :3 BG.ORr�OM r_.. �,,,�• , ,��. . ,. ►.JO GA�'i,C3A►GE:_�jW1.1D6R. ��C'4��C�. I� v A►�.Y,; F�6 fD w I l o x 3 Z 3 o G.P p y�.� . -- - - - - .� _ _ - ,�c�•3 - R �I 5P'TIG TANK • a3ox15o'/• g9r.�.P o - - iao.00 I OISPG'9�I- PIT U 6 G I UGO CG At• "1'Z S`T"O�/crSn. LEacN I ,� 'I D ��r .r ;ga7'raAoYAeEA .. = 78 S.-.�" EX/.sT. . II , 78 S•f X O:F�3 � = (o f G.P. U . Z � 'c�`!,n /3 / � �. j 7 tr7 a4G. Z 4 G.f'a. ' �Zti�A`s� ` . JN OF '•a��. `�9�, ,,- ,? �,4.p�• �Jy /�� OLIO � '•: %pav WILLIAM yGN� Or ALAN cyr, i C. `�- N Y E N ( '] JONES No. 19334 Q F I 1 u. 251 AND SURV p TOP FuU=52•/- .S/• >� i H o t G Z���B3 �.�. SO�a� 1►J`� yc9.� 1 so I ^7,oqW,3Fq GO L. it ALJ4� 0t6T. INJ. SGPTiG i� f!/`iQ>�/4..,.. ;. I D G O i It�!, B u X �• Z ^TANK t ' j �.o�i�tCTr' t 6Q,4✓tr�� = P1T INV. INV. wl-rN y78 4 I ,•`' WA5KGD G�A,P.fr,` 6Tu N6 GERTIF►CO PtoT P1..A1•! La4A'T10N GccAI:7—;%Y/!L �AT � �41,y/B3 r REFE2ENGE 1 C� aTtFY THAT TNE�x�S'T'• 'FN�5No1rYN �. I{6.RGON GaMPt-Y5 1rJITN'tH� �,►p�tt1.1 � �oT /,3© ANO GK 9- QJ12EMEM�f� of-- I EA to w N O I~ 13AZ At-AD ►S I..OGp.TED WITHIN TN6 F1..Oc�D PLb,11N •DAT1r 2. I 3 . 6AXTEQ e ► ` G INC. �Q6'D'►A►�o s ev�Yoes 'Tu►S anScD Old 03TcQVILIE PtwQll NorT - INSTR.VM6NT SVZVjt;`( � 'fHE Ol'F,SET:S Sua�� APPLICA►�T' ' G426: NoT R,F, `vSEOTo DE'TI_F,/^INE L•cT �. IN�.S r