HomeMy WebLinkAbout0065 PINE CREST ROAD - Health (2) (05 Pine creS4 Rd,) W.�
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--�� THE COMMONWEALTH OF MASSACHUSETTS
P A
BOARD OF
HEALTH
' ......�I .----..._OF......1....`............����i..................................
Appliration for Dispute al nrki C�nntrurtion Prrmit
Application is hereby made for a Permit to Construct (�4r Repair ( ) an Individual S
System at: (06' _
.......o-.---..3............ '..? �. L 1- <J�1'I� 4��...................�. �nT y f
.... ....._. ..... --------•----.. .._
Locate n Ad es or,Iaot No.
--........��!e ....................T� t 1 C, �. c.,�A-16J��c_L.............................................................. .........--------
O I / Address
Installer Address
Type of Building, Size Lot__-� f.T:51-_-•-Sq. feet
Dwelling—No. of Bedrooms.__...._..�.............................Expansion Attic ( ) Garbage Grinder Q1Jb)
aOther—Type of Building ............................ No. of persons..................... ..... Showers ( ) — Cafeteria ( )
PqOther fixtures -----------------•------•-----••....................................................... ----•---------------------------•--•---•------------------•--
W Design Flow...................................... .gallons per person pier 4ay. Total q.-........._ Diameter................ Depth..,.
at yt�iow.--......---........__.......___.._....___._gallons.
WSeptic Tank—Liquid'capacity gallons Length.R........_.. Width.:!-- --�__-.
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 ( 1 ) Dosing tank ( )
'—' Percolation Test Results Performed .......Fi..SJ �Yr!`!.... .0 Date..�J_.'.. '_.�
Test Pit No. 1................minutes per inch Depth of Test Pit.........le ........ Depth to ground water.......?................
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 -------••-•--•------------•-•--••••••-•-..... -----------------•---•----•-••....---•-------------------------------
O Description of Soil--h�.._"_ /.//..��.. (��� U Z S � 1 Z' 3 ;14. � S
W _
U Nature of Repairs or Alterations—Answer when applicable__---. E �i NIp C IVC,IiV� H ivil)�� �lJt�1:RVISE
U P � PP� --� Hf��7 C�r��i ICY•Vf� r►v�iiTl1��-----
.-----•-------------.................................................................................••-•---• ryirr M r=`tii'rim ii F►LILIL! Ivi wtif y
Agreement: ACCORDANCE TO PLANK
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 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 board of health.
Signed.....................• ............................................................. ---•••-- •-•............_------
D
Application Approved B .
Date
Application Disapproved for the following reasons---------------------------------•-----------.................................................................
...............•-----••----•---•-•-•••-•••------•-•---•-•---•....--••---•-••-------..........••--•-....------------------------------------------------------- •--------....
.Date
Permit No.�__�. .. � �.... Issued__...----( �' _''.f—— ---._..----
y/
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...'"r��,11�................OF.
%T�rriifirFa#r of Tomplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by........ - P]J 1.Q4- - ........................................ ...........................•------•---•---•--•----------••--•---•-••-•---------•--...........
at.........................rl lam= G1st �lery�-!
...................................................
has.been installed in accordance with the provisions of TI , 5 Th�State Sanitary C e de cribed in the
application for Disposal Works Construction Permit No. ....... dated------------ - —---
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARA TEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. % D-9 ✓'e 'y =7_yd
DATE................................................................................ Inspector....................................................................................
6
THE COMMONWEALTH OF MASSACHUSETTS
--� BOARD OF HEALTH
1.... ... ....................OF.......!.. ...... .. = -
Appliration for Uinpnnal Works Tonstrnrtion ranfit
Application is hereby made for a Permit to Construct ( �Or Repair ( ) an Individual Sewage Disposal
System at:
.....L C�1. .( G r C-}G1 I CCU I L.....................................................
_.. ..._.................................................
Location�A dd ess _ Lot N. -`-r t+� W L,! k► e ul�L ... :�I ...or - ............................ ................................... .
. .........•-•.. ......... .... ......•
1..... O,, n Address
..-•----•.... .•••--•--- --------------------------------------- ---------•-----•-•. --........-- ----•-•-••---•---••--._.....---.._.._................._.....
Installer Address
U Type of Buildin Size Lot... ....Sq. feet
t Dwelling—No. of Bedrooms........... ............................Expansion Attic ( ) Garbage Grinder (pia
Other—T e of Building No. of persons............................ Showers
a YP g ---------------------------- P ( )--- Cafeteria ( )
dOther fixtures ------------------------------------•--•--------------••••••-•-----------••••-•----•--------------------••••-•-•--. ---••-
W Design Flow................................ ...... gallons per person per day. Total daily(flow............................................gallons.
WSeptic Tank—Liquid capacity gallons Length__`._.�'__... Width- ............ Diameter________________ Depth...
x Disposal Trench—No..................... Width.................... Total Length..................C Total leaching area....................sq. ft.
Seepage Pit No.................... Diameter........... _._. Depth below inlet.......:'-)...... Total leaching area...z>Q I..sq. ft.
Z Other Distribution box ( ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date.................... t
Test Pit No. 1__._..._'d�_. minutes per inch Depth of Test Pit........P....... Depth to ground water.._�.t __.________.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ................................................ ............... -
Description of Soil U --••••-----•................•------•----•.....------•----.........----------------2" 3 -�- �7 S l�
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 TITLE 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 board of health.
Signed...................... ............................................................ ................................
D
Application Approved By............................ ........ .... .���� —
----.......
Date
Application Disapproved for the following reasons:------•-------••------------------------------------------------•-----------•-------------...--•-•.....---....•.
.......................................--••-•-----•----••••---.....-••-----•---•••-•-.......•--••--••••------•--••--••-•----•••-•----•---••----•----------••••-•-------••-•--------•-••----•--••---•---
Date
PermitNo. ..... .. ............�--�..................... Issued------..................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
"�\-j t j t� S 11`� P,�-L
......................................O F............. .............................................................
Trr#if iratr of Tuntplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by----------------------k4..._--a .L__-L ---------•-
- ------------ -------------------
G. - I staller
at. '
has been installed in accordance with the provisions of TIT7,F_ 5 of The State Sanitary C e de ribed in the
application for Disposal Works Construction Permit No.__. at-----' -.... -��-.��_. dated_..... �. :. 1.............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARA TEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....................................•----•--•------....._.--••-•---------._.._.. Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
yam_
Nod-t .. --� OF. .................................•--.....---•----........................ FEE...:.. .... .......
Dinp.nllal Vgrks Tonstrndion Vantit
Permissionis hereby granted..........................L........-----•-�L-L--------•L-X---•--•--...............................................................................
to Construct L4 or Repair ( ) an Individual Sewage Dis osal System _
at No.. ...... _...tr .?.. .. h+ N.�:: C•t Z.!.... �........ L� .I -..L.... ...........................
Street < /
as shown on the application for Disposal Works Construction Permit ................... ated..... �f��'�...............
.......................................................
Board of Health
DATE.
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
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Permit Number: Date:
Completed by
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location: L-07 3 P1 N C LKf �� Lot No.
Owner: i CY- Address:
Contractor: Address:
Notes:
STEP l Measure depth to water table
to nearest 1/10 ft. . /
date
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site and determine:
A) - Appropriate index well TSM`
B) Water-level range zone
STEP 3 Using monthly report"Current
Water Resources Condit.ions" .
determine current depth to
water level for index well . . . . . .
mo yr
STEP 4 Using Table of. Water-level
Adjustments for index well .
STEP 2A ., current d&pth to
water level for ind.ex .well
(STEP 3) , and water-level
done (STEP 2B) determine
water-level adjustment . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . .
STEP 5 Estinate depth to high water
by subtracting the water- ;
level adjustment (STEP 4)
from measured depth to water
level at site (STEP 1)
Imo_
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No,24M
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PETER
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No. 29733 � . .;,•,�
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'—` IGNING ENGINEER MUST SUPERVISE
1
j,l�Jp , H"STALLATION AND CERTIFY IN "URITING
TV! �vI,TENI WAS INSTALLED i.`,s ;T;a'P��1 lFit✓Tj"�rjT - FLA 4
GOb 6raL�ai�..�+�c qD/ NCr: TO PLAN,
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DESIGNING ENGINEER MUST SUPERVISE
INSTALLATION AND CERTIFY IN WRITING
THE SYSTEM WAS INSTALLED IN STRICT
ACCORDANCE TO PLAN.
�,St1 OF
:�.^ urnti4m 4
No.
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