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HomeMy WebLinkAbout0152 PRINCE HINCKLEY ROAD - Health (2) J �� �111'�!lMi� ' { i o { { �� - a ©a .� No......-2143------- �� THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ..................OF.....44iyr -�_.t=k .Q-.....C----------.._........---........_...... �a , ppliration for Eli-4pasal Worko Toniiitrnr#ion Permit App � n is hereby m`}�e forr er it to�onstru an Individual Sewage Disposal t S st t -- ' - - •--•• •- .. ---•-•- ---- Location-Address or Lot No. ...................... .�.... ------------------------------•-- --•-•---- /1 l Owner a „ A`nor�ss (�� rA._._...!'1. g ................ ......•--•- i 9•4.... .....,. Installer Address UType of Building Size Lot.e._.�..-. �_..Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (Al)6. PL44 Other—Type of Building No. of persons........................... Showers — Cafeteria Other fixtures .........................-•---• . -•- ---^=--------------------------•---- allons er erson er da Total dail flow......_�..�? .....................gallons. W Design Flow.---•--�-,,�`I-4 r.� g P P P Y Y � WSeptic Tank—Liquid capacity &?`_•:%allons 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 ( ) Dosing tank ( ) aPercolation Test Results Performed by........................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-.--_--______-_-.--_,__. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ n+' .......................................... ................. ........•••-................................................................ O Description of Soil----•---••---... -5.�-.........Ike`1....................................... Z✓1 r =x ---....._•----•------•-••-•------------- V ---•-•-•---•-••------•--------------------•--•-•---...--------•-----------•--...•------------------••------------------•--------------------......-----------.......----••......-•••------•-------•---- 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 boardfof health. q Signed. .... �,.... - ---------••------------- �°"U Date Application Approved By..... ., _ Date Application Disapproved forlefollowing reasons:............................................................................................Da-.............. ..........-•--•-••---------------------•----•------------.....---•-------•-----...------...........-----•..--•----------------------------------------------------------------------------•-----------•- Date - li 7� PermitNo............4fy.................................... Issued..... ..................... Date No......: JV3. ..... Fmc......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF.......................................­­..................... Appliration for Bispaual Workii Tonstrurtion ramit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal . .1, .1 - t t" Sys ema ...............i .............. ................... ./Z�...�e................................................ -,,,Location-Addres.§ or,Lop No. . Ar141!r............................................................... ......................I..................... ....t..o 9 Owner A. r..e.s ............................................................­ 7 . !!JCa s - ---- -------- ...... . .... Installer Address ,, 14 Type of Building Size Lot.. ................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder aOther—Type of Building ............................ No. of persons.........._................. Showers Cafeteria Otherfixtures ..................................................................................................... .............................. Design Flow______._____;. 3..............gallons per person per day. Total daily flow--................_ ._............ ....gallons. 9 Septic Tank—Liquid capacityii1._'�.1.:'.`jallons Length................ Width..............._ Diameter......_......... Depth................ W ? "� Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................sq. f t. Seepage Pit No..._j s Diameter f-I!..........f"'Depth below inlet.................... Total leaching area..................sq. f t. Z Other Distribution box ( 7 Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ 4 4 Test Pit No. I................minutes per inch Depth of Test Pit........._........._ Depth to ground water.......--...-_.......... lw� rZ4 Test Pit No. 2................minutes per inch Depth of Test Pit............._..._.. Depth to ground water...-_........-.......... P4 ................................................................Y.- .........�F................................................................ 0 Description of Soil.................e�.&#44.e.......6/en et._.......... ............................................ ............................. W.11 ......................................................................................................................................................................................................... --------------------------------- ---------------------------------------*-----------------------*-----------------------------**------------***--------------*......................"----------- U Nature of Repairs or Alterations—Answer when applicable................................. ............................................................. ...................................................................................................................................I.................................................................... Agreement: The undersigned'.agrees to install the aforedescribed"'Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of. the State Sa_hitd-ry.-..Code— The bndirsigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board i'ofiealth'� . jj..............................Signed... ...................... ... V..................... Date r ApplicationApproved By......... ---------------------------......... ----------------------------------- ------------------ Application Disapproved for ke following reasons:............................................................................................Date.............. ......................................................................................................................................................................................................... Date Permit No...........7.4rj?.................................... Issued...... .................... Date COMMONWEALTH OF MASSACHUSETTS- S,BOARD OF HEALTH 0: ................. 0 F............4:e� ........................................... Y ffiratr of =41fialtrr .Trffi W1 THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired by.............. ........1.5 ............................................................................................................................. at Installer / - " r............ ....... ......... 41. e4F��7ir,*4111e- ,/ 5 .............. .... .................. x....... -------------I-----------------I------ ------------------- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Per*mii'No y_.,-2�.3.-..7..!.�................... dated....... _.._..._-__._._._- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTIOtLSATISFACTORY. DATE......... .............................. Inspector.-- ... ....................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF ':WEALTH No.......... .... ....... ..........72!e.461PL­ ....OF........................ ......................... FEE........................ Disposal Varks Tonotrwtiott an it Permission is hereby granted............A(.?F4 4.e .........--k,(.4�A�.................................................................................. to Construct ( A) or Repair an Individual Sewage Disposal System at No. h, t . 40104 ........................................................ Street as shown on the application for Disposal Works-Construction Permit No. ._ .... Dated....../�—Y7.21............ ......... ...................................................1.le ....*-----------------------------Boar 'of Health DATE. .................................. FORM 1255 HOBBS &,WARREN, INC.. PUBLISHERS _911 rLcc Q r ,:� �n. 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