HomeMy WebLinkAbout0063 PRINCE HINCKLEY ROAD - Health (2) nal��
No......I/..............
F��.. . ...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OE HEALTH
I��-I� � O F -- -----_------------------------------------------
Xpp irtttinn -fur ii.ipl ml Works C om4rurtion Vrrniit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
-ion-Addr r Lot-No
-O er Address
W
Installer Address
Q Type of Building Size Lot... ...Sq. feet
U Dwelling—No. of Bedrooms---__- __. __________________Expansion Attic ( ) Garbage Grindera )U
pa., Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures ------------------------------- --
Q •-------------------------------- p
W Design Flow------------------�#......._.........gallons per person per day. Total daily flow......._...!'-_ ___.........gallons.
WSeptic Tank k Liquid capacity/16 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 (b) Dosing tank ( ) f q,-7vl
aPercolation Test Results Performed bY.......................................................................... Date------------------------------------.---
,� Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water..-.-.---.---.-.---_-.
44 Test Pit No. 2................minutes per inch Depth of Test Pit--_-__--____.-_-____ Depth to ground water--.-.--.--_----.--_-----
....... - --------•-- --------- i- .
•--• • . ..•..11----•- --/-------
O �--- ) f �
ion of Soil — -fP-------- t_ ��h / v_� y l , Ge
x ` _ _
W _ YYYYYY GGGiGG� --- ----------- ....
/ Y.=W --- --�! --
i
VNature of Repairs or Verations—Answer when applicable.----------------------------------------------------------------------------------------------.
---------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewag isposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned f ier agrees not to place the system in
operation until a Certificate of Compliance has been is ed by the bo of h lth.
Signe -- ---• -- .-- --•---- .-----
Date
Application Approved BY ------------ ------Z l�Z,
• D e
Application Disapproved for the following reasons-----------------------------------------------------------------------------------•-•----------------------•----
.....................•------•-------_...----------------------........------------•--•--
Date
PermitNo......................................................... Issued...................... .................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
,
_OF.........../c -f-:t"��' -.A �-I �!
Appliration -for J%ipoiial Morks Ton,itritrtion Vrrniit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
x hocafion•Address ` or Lot No.f 1
Owner //� Address
Installer Address
Q Type of Building Size Lot..../.)-__--_ feet
Dwelling—No. of Bedrooms------S__--------------------------------Expansion Attic ( ) Garbage Grinder d(d)
I:Lq Other—Type of Building ---------------------------- No. of persons.------------_-------------- Showers ( ) — Cafeteria ( )
QP' Other fixtures --------------- ---•---- ...:.
----•- -------------,�--�- ,,``
W Design Flow..................... per person per day. Total daily flow___-________Z_w-__- -.-..._...gallons.
WSeptic Tank t Liquid capacity JZs�gallons Length---------------- Width................ Diameter-----...._...... Depth.__....__..__.-.
x Disposal Trench—No- -------------------- Width-------------------- Total Length.................... Total leaching area--------------------sq. ft.
3 Seepage Pit No------------------- Diameter-------------------- Depth below inlet____..__._.......... Total leaching area._.--.-_.-_.--_-.-sq. ft.
Z Other Distribution box ( ik) Dosing tank ( ) 0 2, f 4) dF -it- 7le
Percolation Test Results Performed bY-------- ----------------------------••-••----•............------•---___.. Date........
Test Pit No. I----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water.._.-.--.--..--..--._.-.
44 Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water---------------.____.._.
oil. � - - ---•--------------•-•- --------
escr S ---n A/ � .
..< _
z6v�, _7
VNature of Repairs or terations-Answer when applicable.----------------------------------------------------------------------------------------------.
--- -- -------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage,,Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issuedd by the board.of health. J f
Signed c ---
---- ----•-------- ................................/
ate
�APPlication Approved BY------- . ...
!� Date
Application Disapproved for the following reasons---------------------------------------------•------------------------------------------------------_------------
•----•-----••------•------------------------------------------•--------•-------------•-•-•-•-------------
------------------
Date
PermitNo........................................................ Issued..................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.
.�'!: .f?, ...... .. ....OF.......... - - v'�.-.. ....................................
r1fT.rrtifiratr of IT."omphaurr
THI �lS TO r7gRTIFY, hat the Individual Sewage Disposal System constructed ( or Repaired ( )
by
7
(
at /
eInstaller -_-•---__.f•-
t J G `l L✓_' r-------- ------
has been installed in accordance with the provisions A 1-lei�''I of The State Sanitary Code as describe in the
application for Disposal Works ConstructionPermit N l� _ _. -.... _ _
THE ISSUANCE OF THIS CERTIRCATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WIL9L FUNCTION SATISFACTORY.
DATE 1.. �� - --- r( Inspector------- -__ -
THE COMMONWEALTH OF MASSACHUSETTS
�1 BOARD OF HEALTH
.......OF............ a.J.4/1
No. .................. FEE... ------2 ..
Permission i� reby granted_-.". =' r:! � =------ �t
to Construc ( -' or Repair ( Indiv 1 S -age Di posal Sys
at No.."
--- tr � r
s eet 7- '-76
as shown on the application for Disposal Works Construction t No. ___.� ... ' ,ated___.......................................°
DATE........ _ ._� -----------------------------------------•- Board of Health 1 V
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
' S
,t. y , -• _. I "' , • r .. ,r_" t S w..� • yam* r u �
y
3
lyy7
033
w
of
L.c�`gy
{
y ` CERTIFIED PLOT' PLAN
NEW CONSTRUCTION ONLY :'
NLY ;' "^��" �`�� `a � � ���A•�t. �ic ,,
TOP OF FOUNDATION IS 3 w FEET IN ,
ABOVE LOW POINT OF ADJACENT bAJ1J11SIA LioAASS -
SCALE: DATE - `
E D EDGE ENGINEERING CO.IN A $,,��/C I CERTIFY THAT THE
CLIENT _` ;SHOWN ON THIS PLAN IS LOCATED
01STERED REGISTERED JOB NO.73 ON THE GROUND AS INDICATED AND
CIVIL I LANDp� CONFORMS TO THE ZONING LAws
ENGINEER SURVEYOR DR. BY OF BARNST B , MARS.
33 NO. MAIN ST 712 MAIN ST. CH. BY:
SO. YARMOUTH, MASS. HYANNIS, MASS. SHEET OF ® DATE REG. LAND SURVEYOR "£
.,;�a