HomeMy WebLinkAbout0068 WILD GOOSE WAY - Health -68-WILED. GOOSE WAY; CENTERVILLE
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UPC 12534
No. 21 3LOR
}CASTINGS. UN
I
ASSESSOR
No... S MAP NO: A�� / O
.---------- PARCEL ...............
� THE COMMO A SACHUSETTS
G/ BOARD OF HEAL/TIR—
/ ..................OF..e-qrs4.6..-.le.....5... e.Yt 'i �
Appliratiou for Mspwial Permit
Application is hereby made for a Permit to Construct (, or Repair ( ) an Individual Sewage Disposal
System at• -�%
413
..
f� Locatio is A••-ress � n-•� � ••'•
�- S! or Lot No.
A�yye�
O ,er ddr s
a �`� ek.,.��.�.�•�.? :+�i�l�:��:_ca.�,�.i.�� ..�.�•:.L�:•J�.�x.�.�.A.�---f'�'�:��.�d,�.le..,--:1:�1�:.�.�e��
Installer Address
Type of Building �L Size LotZ5 f..aP-..?Q_..Sq. feet
.-+ Dwelling—No. of Bedrooms-------------2.--_-_-__-_--_--__-_-----_Expansion Attic ( ) Garbage Grinder ( )
aM Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q Other fixtures / ..•._..•• .....
Design Flow............../.1t...................gallons per person per day. Total daily flow...........� ;�! '.�.... ...........-gallons.
Septic Tank—Liquid ca.pacity4�llons Length-/Q-/...... WidthS�- /.UDiameter... 5.�Depth. M..a.'o
Disposal Trench—No..................... Width.................... Total Length---...--......--.... Total leaching area.
................... ft.
3 Seepage Pit No..---.--.�-..... Diameter.-... ... Depth below inlet.....-3-_:5..... Total leaching area..ftO...sq. ft.
Other Distribution box (1_)� Dosing tank
a Percolation Test Results Performed by.-.•-<:Z,... & 2;7... !e ate..... .-..1. .-��-�-0•...
04 Test Pit No. 1 L.. minutes per inch Depth of Test Pit-.-/�pg � epth f ground water./90'4-6-...�Y1C.
f>~ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ............. .................r .........................................................
Description of Soil.....
L?Q.«-- �Y -. ..' 1...4f -•---4e�lC �r---�U�7Se�ll !�f !i _ 9��i
/
4�
...... 4 .... .................
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'ITL: 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 bo of,iealth. D� , l /i ��
. J
Signed...... .. .. �- . �_ d.�. ............... ......�./.�.
J
Date
Application Approved By.. - .............. ........................................
Date
Application Disapproved for the following reasons:---...-----•--.•..................•.._--------....----...---...------.-------...•..•.. .........__..
..............•---............--•-------•-•--•---....---..-..._...---................--•--...._.•...............•.......-•-•-••••...•---•.....---.•.....- ............... ..........................
Date
Permit No.. -- ... Issued...... _
............. Date
-----_��--- --- -,fir �� ��-�-�`_-•- ____--__
No......................._ C3 -^ F>�s............._....
THE COMMONWEALTH OF MA SACHUSETTS
BOARD OF HEALTH
LUf�..................0F..F4/..-//.;�
Appliration for Diipooal Nforks Tonstrurtion lirrmit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
system at:
.....�I� /� s.. ... ,> ------------------------------ ---�............-------•--....----...................
__......,. -_... --------
,,aLotion-Address
�wL or Lot No.
. •4n.= Zf ....:!..?..�f....
rOwner j Add
. !'.•...401.2 -. �J'SL 7`
•-
T Installer Address
Type of Building Size Lot7' .r. .`/ ..Sq. feet
0-4 Dwelling—No. of Bedrooms............�.........................Expansion Attic ( ) Garage Grinder ( )
Other—T e of Building ............... No, of ersons..........._........._._____ Showers
a YP g -•-•----..... ------•---------.P ( ) — Cafeteria ( )
Otherfixtures -------------•-•--•-----•-•---• ...-••••---•-••••--•--•--•--•••••-•--••--------.....
WW Design Flow............... ...................gallons per person per day. Total daily flow........... ..................gallons.
WSeptic Tank—Liquid capacity-`-61�gallons LengthAD........ Diameter.... Depth. T�.—. .
x Disposal Trench—No. .................... Width.................. Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No..__....�-_.... Diameter.._.. ....... Depth below inlet.....?'--:-5..... Total leaching area.., 4'?...sq. ft.
`z Other Distribution box (tf)�'� Dosing tank ( )
` /
� Percolation Test Results Performed by..... �....... .
Test Pit No. 1�7%.2:....minutes per inch Depth of Test Pit.._I/,-P Q".. Depth 4/ground water./.-?.04.to....to.."C.
Lit Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a '
-----------------......--•--•- ---•------ ---
n..........................
...... --------------- �--.1------- �-- --------- ----------------
Description' of Soil..... ......:..�:.[..._.....�:....-•----...- S'i��«tl.._.. -`,�l.i. �r.r-�
�-.�y
UW ..........................-------•••-•------•-•-•--••••-••---••••-----•-------•••.......-•--•--•••---------•---••-•••-----••......•-•-••••••-----••-•--•----••---------•-•--•-- ..k .:....-
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 L 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 boar=- 4ofealth. J Q 3/1a147,
Signed..� r ' :✓...... � .. _ .. ..t
Application Approved By__ �� Date
,......--•-. . . � ...
........................................
Date
Application Disapproved for the following reasons:................:..................•--------------------------......-----------.....--••._...---•-••........._..
----------------•--- ._.._..... ..-•-•-•--------•-•-••--•...--•---•--------•-•--••--•------.....---- ,. Date
Permit No. / l/
........:..... Issued_
Date
_.n____..-._-_r_______..__..__ `- ------ --_----r_______-__-w_-__-__----- - --- --- `- -------___� -
THE COMMONWEALTH OF MASSACHUSETTS
1 � BOARD OF HEALTH
11,1/./....OF...........o.(1...!.l \/,t!,,. :�...!..�.. ..
Trrtif irate of Toutphattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
bY- - :.....,A I • 'tt-"� ---------•-••----•-•-----•----••-• -----•-•-•.........................
Installer
at...... " .. l-. �' /GaO....r 6 �i( ....
" /! � . ZZ'-`-#.............................
has been installed in accordance with the provisions of TITtP, 5 ofc h tate Sanitary Code s described in the
application for Disposal Works Construction Permit No----- " :..5? -----. dated.....
Y r / err THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. ✓•� a?-
DATE..................(! "..�. . . ................................. Inspector......... = ............................................................
---------------------.---- _ - --- --•-------------------•--..-------•-_--_-.._,-,.
THE COMMONWEALTH OF MASSACHUSETTS
6/ BOARD OF HEALTH.
P/0 a ....Z�ni 161�N o ..... -:- . ...--•------......•••................. ///(9 ..--
FEE.
Disposal lVarkii Tonstrurtiort f rrmit_ ,
Permission is�hereby granted-. .:_ Jam' - - ��?�_ /t:t:.-.... ..................................
or Repair ( ) an Individual Sewage Disposal Syste
mto Construct (�� m
at No.... / !` / .- ( li.��`�..� .................................
-----._... _..................... _•
Street �,�__/ �-7 /
as shown on the application for Disposal Works Construction fPermit. No.............. Dated�� -�7�(�.........
�-' f I ..''�r- ''�,/'er7.. . -- ''�.....
/ X f hoard'of Health
DATE----------------------=-----r.-•./..........--- .........-•----------......... y .✓
pia j?:,p i
/ 10119l1. .
999 10: 43 5033336359 R J EEJILACQUA CO PAGE 01
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TOWN OF B STABLE
LOCATIO ® —� SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT) b_
INSTALLER'S NAME&PHONE °'NE NO ` 'Bf VI( U U
SEPTIC TANK CAPACIT IY S M Q11n n
LEACHING FACILITY: (type) i r,� (size) 4 Iwo cinl11110
NO. OF BEDROOMS 4
BUILDER OR OWNER , Li(C q
PERMTTDATE: i"L COMPLIANCE DATE: 16 -11
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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1645 Falmouth Rd. — Suite 4C Centerville, Ma. 02632
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