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HomeMy WebLinkAbout0097 HEADWATERS ROAD - Health 17 Pead w otterS CAA i err ti It e I/ S M E A D KEEPING YOU ORGANIZED N©. 12534 2-153LOR NARLE FORE RY MIN.RECYCLED jGX INITIATIVE CONTENTIO% CemfiedFibersourcing pOST.CONSUMER www4prMpreetorg sRmpo UAI)E IN USA WTOWUMMATSEMM r L VAT No. �s .- _.�--•- Fxs....�©............ THE COMMONWEALTH OF MASSACHUSETTS EOA R® 11 I E A L.T ICI .r C7f�lt.................OF...-......... —.5. J ro�% .......................... ApVt#Fation for Disposal 19orkii Tonotrurtion Urrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: _ Loca on-Address a ..�o ..v... LID ............................. 1 �c�__�.� t- ._---•- . dreqn" . Y QtJ Installer Address Type of Building Size Lot____.22 ®4Q_+5q, feet U Dwelling No. of Bedrooms.._..___.g— -3_____________________________Expansion Attic ('44 Garbage Grinder W�, aOther—Type of Building ____________________________ No. of persons............................ Showers (' ) — Cafeteria ( ) a' Other fixtures _________________________________ W Design Flow____._ _--_q_ .__ allons per person per da Total dais• flow________ gal g g P P P r Y + !Y 3L? •--- 1 ns. WSeptic Tank—Liquid*capacity__/OOV.gallons Length_______ _______ Width_____ __....... Diameter________________ Depth______ ..... x Disposal Trench—No........602..... Width.................... Total Length....... __........ Total leaching area.................___sq. ft. Seepage Pit No...................... Diameter____________________ Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box (g) pE�{ Dosing tank ( ) aPercolation Test Results, �'4 m Date--- ,a Test Pit No. 1_h..i, ..'r�nmu es per i epth of Test Pit.___ 1_______. Depth to ground water_.11�_______-. (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..................... W ..........-....... 0 Description of Soil....... . r�•. ................•-------..-.....------------••••-----•••--•------------•---•---•-_...------------•-•-•---------.......---- v ..................•----••---- �! `� =1=71e.......-----------••----------------------------------......------------.. W VNature of Repairs or Alterations—Answer when applicable............................................................................................... ---------------------------•-------------••----••-•--•-•--•---•-----------...------•----...-----------------•--------•---•--•-----••-------------••------------•---•-••-------------•••----•------•---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in ac ordance with the provisions of TITLZ 5 of the State Sanitary Code— The undersigned further agrees no ,stem in operation until a,Certificate of Compliance has been e byf e oar - Signed------ ---•---•- -----------•---------•--- •-• -- ••.. ------ Application Approved By.............. -•-------------------- ate ..._._...---••--•-••- Date Application Disapproved for the f o owing reasons---------------••----------------------------•---------••----------------------•-•---------------••-------•-•-•-- .............................................._.......................................................................................................................................................... S Date PermitNo......� ----•---------•--------------- Issued...............................................------- Date a--- - -- -------- THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Yt7 OF............ A-4-L 'S. f.- _ _____________________•---- Applirat uri for Disposal Works Tontitrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at • .� s....... ..... ---------•••---••......_-----._... ....7C 1Isw Tocation-�ddress Lot No, ..................... Q &s..-------•----...._.._..... ........ .i2l._' AdessOwner - + ,� �2�►' i.�,r..1..'� i� .............. ---��-t� �/. -•------ ------ =! f,,�. ----...... � � •-` `�, Installer A re ss Q Type of Building-;:;1,; Size Lot____ -��' -Sq, feet U g— s._:,_.________3_________________________Expansion Attic f(V�) Garbage Grinder ) a YP g 0 Dwelling No.:of Bedroom Other—Type of Building ___________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) aI Other fixtures ________________________ w Design Flow............ _-c/3-------_...........gallons per person per_day. Total daily flow______________.3.3-0..............___ lons. W Septic Tank—Liquid*capacityJA0.0gallons Length....... Width______________ Diameter---------------- Depth___ ------- x Disposal Trench—No, ........._�0. Width.................... Total Length..__-__._./6.._._. Total leaching area--------------------sq. ft. Seepage Pit No................ Diameter.................... Depth below inlet. Total leaching area..................sq. ft. Z Other Distribution box (j Dosing tank ( ) Percolation Test Resul)s Performed by.......................................................................... Date............................ .......... Test Pit No. 1 _8_hl...;'inu e _r inch Depth of Test Pit_ 24.7.____. Depth to ground water. /--______--. fq Test Pit No. 2............_...minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ---------------------- --f•----•-•--.____••----•---•-•-----.... D Description of Soil............. lr+_____ x ------� 2-------------------------- c� w � V Nature of Repairs or''A'iterations—Answer when applicable. --------••••--------------------•---------...__----------------._...-----•-•--------...__-----.....•--------...:------------____._.__...,.............................................................. Agreement: The undersigned ,agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIZ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a.Certificate.of Compliance,_has been e by board of health. Signed- ••-------_...- ate Application Approved Py__________________ __ ` -----••--- -------------------------• ............... ........................................ Application Dist,prove�'for'the foCl. ..,ing,reasons:.......................... :- Date ......._.� x,. ..........................................................................................................__.._.__._______,______.__-___.___.___.____________.____________________.._________.____......_ Date .Permit No........ . ..................................... Issued. ::.: .................................... Daie THE COMMONWEALTH OF MASSACHUSETTS BOARD HEA•L�T 1.. -........710. ✓ni...........-OF............. aft�'�,s.r.T`(L . ............................ Trdifiratr of Toutplionrr THIS IS TO C R WY, Thq the Individual Sewage Disposal System constructed ( or Repaired ( ) by ______________•-----------------_____.---------•--•------•-•-------------- ..•----••---•-••••••-••••---•••- Installer has been installed in accordance with the provisions of TITLE f State Sanitary Code as described in the ermit No________________________________ _______ dated---- application for Disposal Works Construction P THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON RUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. D ATE.......... ...... g ..................................... Inspector........... . .......................................... THE COMMONWEALTH OF MASSACH ETTS BOARD O HEAL H ` 'C`� �HA a No.........Q............ FEE........................ Diuvou;11 ku �o .rrutit o �M e� Permission is herebyranted �__'_ ,•,, g 9....... --••-•- - to Construct ( or Re�Pair ( iilrirdiI idu�l)prgage I&VtjaLVstem atNo.................................J-••-------••----- Street :r� t ' �- '.. as shown on the application for Disposal Works Construction Permit No __ Vt�......................................... •......... .......e----•---...----•---... a ........................................... of Health DATE =-----•----- -•--•7_—-•------ r; - FORM -1258 A. M. ULKIN, INC., BOSTON . LOCATION Lbi --V-5 SEWAGE PERMIT NO. PILLAGE INSTALLER' NAME i ADDRESS eun- S U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED � 2 1 cAxL5Ace j o w 6-P Gf u C— %000 P L2 p E 51(5 TOP wu 72 10ou INS rj INV. II PLo-r PLAN P>Z 10�j No N07-54 wo* CA L F- gL-r 'T 14 AT 'T ,4Qp r,,OW CoMpL%�!5 IWITO g:fA s Awo -Ssereq&CVC A N ID I IF-P T— u X'61 C>6TG2V1 L Lr- o Od A w -T.ke 11", r15F-'Ts 16woutT� -r I � e>vev APPLICANJ -------------- e9z s I 24 ' t c� r <ISvt 3g %or ra SE s10' sriX i iJ :o;�b i .f::r