HomeMy WebLinkAbout0041 PRINCE HINCKLEY ROAD - Health (2) C�►�-
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Fps........ ..�.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HE LT
T� 1�..........OF.......
.
Appliration -fear Di.ipnsal WorkD Tomitrurtion Permit
' i hereb 'made for Permit to Construct or Repair an Individual Sewage Disposal
Application s y O p O a p
��r Sys at: / � IF,7
� ..._... ........... �- ....... .......
L Ad a oa *
�...........:.......................................................... .............. .............. -------••-----•-...-------•----------------------•----•••------
O _Address
Installer Address
Type lofuilding'_�
Size Lot_.___ da .Sq. feet
V Dwelling—No. of Bedrooms--_-------�--_________ _____________Expansion Attic ( /� Garbage Grinder (N�
Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ---------------------------------
W Design Flow............................................gallons per pet-son per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacit'✓ _gallons Length................ Width..---..-----.--- Diameter................ Depth_-------------
x Disposal Trench—No_ ____________________ Wi th-----_--•__-_----_-- 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 ( ) C �, /C �- l,p- 2 7- 7 ,'
PercolationTest Results Performed by-------------- ----------------------------------------------------------- Date------------------------------------....
a
Test Pit No. 1----------------minutes per inch Depth of Test Pit-................... Depth to.ground water.:__--._-----
�14 Test Pit No. 2................minutes per inch Depth of Test Pit.--_-_--_-_---_.-_-- Depth to ground water--.--..-_-_-_----__-.---
0 � �}
O K _ F-'....-..�.. - ----- �r� ��
Descriptio f Soil- n' ---- -- --•- ��------ -----U=w_ ..
vNature 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 Article NI of the State Sanitary Code—The undersign further agrees not to place the system in
operation until a Certificate of Compliance has been i ed y th o health.
gned_.. . -- • -- .......
..... ................. � �
Date f
Application Approved BY "- � �----------------- � 7
Date
Application Disapproved for the following reasons----------------•----------------•-------•-------.---_.-------•------.---•---------------------------•-----------
-•......•---••---•-------------------•--------•-----------------•------------------------••----•--•.......---•------.........-----•-----------------------------•-----------------...---...----------•---
Date
`2 ` 77
Permit No. Issued.. r- ------------ ............................
Date
z..
y r
`w
No.....116- 1 FE$....... .f.................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........OF......
A11111 ration -for M-4patittl Works Towitrurtion VPrui t
Application is hereby'made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal
System at
xLocation Address..Owner
W .. � Y ..e f ry^ . '� Address
— � •-- --- -------------------------- --•---••••--------------- ------
Installer _ v Address
d Type of Building ,� Size Lot_--._.1.. -___� Sq. feet
U Dwelling—No. of Bedrooms.._-____..-^..._________________________Expansion Attic (OV,�, Garbage Grinder (N
aOther—Type of Building ___________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
dOther fixtures _._._ -----------------
W Design Flow............................................gallons per person per day. Total daily flow........................._--_--_--_---_-gallons.
9 Septic Tank—Liquid capacity/!e""o_gallons Length---------....... Width.........-:_--_ Diameter---------------- Depth................
xDisposal Trench—No_ ____________________ Width___-------------------- Total Length-----_.............. Total leaching area--------------------sq. ft.
Seepage Pit No..................... below inlet_._.__ Total leaching area........_ __-____sq. it.
Z Other Distribution box ( ) Dosing tank ( ) ' • � �� "`
�-' Percolation Test Results Performed by--------------------•- --•------------------------------------•-----•------ Date........----------------------•-------
,� Test Pit No. 1----------------minutes per inch Depth of "hest Pit-------------------- Depth to ground water-.--__--_----__-_----.
(� Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water__._--_____-______--.
a --------------- -- F • --
O Descriptio f Soil r` upe" - r• � .1
..............J-' s.Qt--A ----J : � / far' E: i -----
w
U Nature of Repairs or Alterations—Answer when applicable.-__.... ;_:-------------------------------------------------- ------------------------
------------- .
.+ -
Agreement:
r The undersigned agrees'Io* install the aforedescribed. Individual Sewage;Disposal Syst6n in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigtiq further agrees;not to place the system in,
operation until a Certificate of Compliance has been issued`` y the b and of/health. .
,>F find t f-• r ! "
v - .__ --------- Daotee rr
,
Application Approved By-._!,!t ---- +►`
ate
Application Disapproved for the following reasons____________________________________________.____. ..___._. ________. _.._._._______...._..._.._._______
.............•-----•---•--------------------•---------------•--••-------••-•------•---•---------•-------------------------•----••-•------------••••-----•-------------------•--------------•--••-
Date
Permit No................. = :' Issued.---------- =------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF - EALTH
0F.......... ...... a C.•..... .. ......................................
Trrtifiratle of Tompliaurr,
THIS IS 0 ` .R" F , That the Individual Sewage Disposal System constructed ( or Repaired ( )
.+ w
by---
Insta} j`
at..... v'-... ._. .. ��".......... �-' _ ` - ---•---•---•---___---
has been installed in accordance with the provisions of A tc XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.___________ ................. dated..... '/"!'�-! '_'"_ .. ...__.._.
THE ISSII,ANCE`..AF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
---- ---7- ------------ Inspector---- .......................... --......................................
THE COMMONWEALTH OF 'MAASSACHUSETTS
BOARD OR. HEALTH
No.. ` -- FEE.....�......••------..
-
Permission i eby granted,-
to Cons r 9T Repair an ndi •dual ag ispos Syst
at No.
Stre,
as shown on the application for Disposal Works Construction Perrntt o
4Dd------ ..............................
'_ ? Board of Health
DATE= µ ,
FORM 1255 HOBBS & WARREN, INC.. -PUBL18HERS -
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