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Home My WebLink About0240 PRINCE HINCKLEY ROAD - Health (2) Plt,4nicc, No............ .................... THE COMMONWEALTH OF MASSACHUSETTS BOARD qF HE LTH ------------- OF........J. ....... ............................... - -- ----- Appliration for Disposal Works Tonstriartion 11trutit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal SystemA: ZkYL) ............ . ............... ........ ......... . . .. . ........ .... r --- .......... ................. ....... n....... E0 jon Lo tion-Addres ........ ..... ........... ...... ....... ............................. ................. .............. ......... . ...............Owner --Ilddre,,r,................. . . ..................... ...... .............. ... . . . . ..... .......... ..... .................... .. ....... ---------- Installer Address Type of Building Size Lot..../4/471b..Sq. feet Dwelling—No. of Bedrooms........... .................I........Expansion Attic Garbage Grinder (A, ,p P4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria P4Other t T —---------------------------------------------------------------------------------------------- ........................... Design Flow________ gallons per person per day. Total daily flow............................................gallons. '/'ft-...... ....'"1:4 Septic Tank—Liquid'capacity gallons Length________________ Width.__.__._._...__. Diameter-_._...____.____ Depth_._____.___.__.. W y Disposal Trench_lNo. .......... Width___.___...._.___._.. Total Length.................... Total leaching are�.....................sq. ft. ,Z Seepage Pit No.._... ...... D ete4p Depth below inlet_ ............... Total leaching area..................sq. ft. Z Other Distribution box Dosin!ta., Percolation Test Results Performed by., ............... ................ Date_.__..0....7if............ ..... -- --------------- -- Test Pit No. I................niinutes per inch Te7l"l-Of Test Pit.________.._..______ Depth to ground water_._._._____.____._.____. Test Pit No. 2................minutes per inch Depth of Test Pit_____._.___-________ Depth to ground water___.___.._______.__.__.. ............................................................................................................................................................. 0 Description of Soil........................................................................................................................................................................ W ......................................................................................................................................................................................................... ....................................................................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ................................................................................................................ ...................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual S age Disposal System in accordance with the provisions of TITIE 5 of the State Sanitary Code—The undersig d further agrees not to pl ! the system in operation until a Certificate of Compliance has bee i s by thud health. Sign ... ....... . .......... ........................................ ... Date . ............. Application Approved By___..___ . ........ ... ..... . .. 7 Date Application Disapproved for the following reasons:.............................7 ................................................................................. ....................................................................................................................................................................................................... . Date PermitNo......................................................... Issued...... ...l........e..�................. Date q: >4 ' No....--....7........ Fes$... ............ .4. THE COMMONWEALTH OF MASSACHUSETTS t . ` BOARD OF HEALTH t AV irafiou for Disposal Works Tontitrurtiun Famit Application is hereby madeJor a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at gP,l�Y g .......... .. �...« .... ............... ....... _....- Location Addres j� j No. .... ��f.. •�/'t-4-•;tom..._. .......� ... .:...«.-. ........... --- t Owner' Address p a �-j+ i .: i"` r t �c,�....................... --....._...�" rr�: aka' *.�. .....................................�i Installer Address UType of Building Size Lot.... -V4Z�:--------Sq. feet Dwelling—No. of Bedrooms........... '...........................Expansion Attic ( ) Garbage Grinder (1V'O '4 Other—T e of Building a Other—Type g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Othertunes ---------- -------•- -------•---------------------------- ----- ell .. w Design Flow------- _:•_:-:•-•...:........:.......gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacit ft gallons Length................ Width................ Diameter................ Depth....4_,._._.._._ x Disposal Trench N0 ............. Width Total Length.................... Total leaching area....................sq. ft. Seepage Pit No... � . Diametet� ;. Depth below inlet_ ............ Total leaching area..................sq. ft. z Other Distribution box ( ) Dosan Percolation Test Results Performed b :.!�ank -r. :. Q�YDate ... ... Test Pit No. 1................minutes per inch De th of Test t._...._.... ....... Depth to ground water.. __.............__. 44 Test Pit No. 2...............minutes per inch Depth of Test Pit.................... Depth to ground water........................ .- Description of Soil........................................... . ----------------------------------------•--•----------•---------••-••••-_.._..-----------•...----•-.-•-•- x w UNature of Repairs or Alterations—Answer when applicable............................................................................................... ••-------•-----•----•-•••-•---•••-----•-•--•••••-•-•-•-•.................••-•••••-----........::....----•---....-------•----••--••--•---•------•-•------•----••••••.....---•........................... Agreement: The undersigned agrees to install the aforedescribed ..Individual SeyQbage Disposal System in accordance with the provisions of I: `� 5 of the State Sanitary Code— The undersig eld further agrees not to p1 .16b the system in operation until a Certificte of Compliance has bee s by the board f health. Sign ... ......... ................. ---........-----••. Date Application Approved By........ --- ' . . 4 !1/L -----.......••. Date Application Disapproved for the following reasons------------ ---- •••• ...........................................-•-------•........................ ..-•----....•-••--•••-•--•-•.................•-----•••-•----------••.....•-----••......_....-----------------•••--••••••••-••---•--•-----•-•-••-••-•------•---••--•----•-•--•.......................... Date Permit No. ------------------------------ Issued................................. Date .Frf� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ .........OF............. .. .............. at ifiratle ,af 9outplinnrrTHIS S CE TIFdividual Sewage Disposal System constructed ( or Repaired ( ) by = -------------- -- -•- l� at....,..- T P "ae�t Q '�"' Gam'---• --- . has been installed in accordance with the provisions of 5 oi T.he State Sanitary Code as described in the applicationrfor Disposal Works Construction Permit No. .... ........ ------------ dated------ --��'_.�'---------------------� { . THEy;ISSUANCE OF THIS;CERTIFICATE SAAL,L NOT'BE,CONSTRUED AS A GUARANT THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ,.* DATE...............................•-----------.......................------_----.. Inspector._..._`.::.. -= =.............._...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OJL HEALTH y y�`� OF..-- :..act- FEE . t t �tl iott rantit Permissi n is hereby granted....... ' to Constru t ry or Repair ( n 4ndiv du ewage > 'sal S at No.-- --- ........'Z � - `" ? :......_. -r Street as shown on the application for Disposal Works Construction ermi o ................ at _... `! ............ .................. .... • •-- •-- _ Boar of Health DATE.....................-......................................................... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS �. �/NcE ~ t�'StQG1_& V-76nnit✓1' _�� I SIE:D ZOOAvc QO G,A2sAt E brzt��sz 1`Low = 110 X 3 S3 o G.P•t7. +4 t % USA- t o00 6A L-. 15PO5AL PIT - uSE loco CD�c/ALL Ae tSo s.17. a 9G (Y. S.P . Thht� N!S TOTAL 1:;)ES16KI = .4'L5 (-.P.D. TOT&L TDA.t t_'-f t`C.nW F?D:= d X exP. 33D 6. 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