HomeMy WebLinkAbout0326 PRINCE HINCKLEY ROAD - Health (2) I 1
N -••• 1�'EB.4 ............. ...
THE COMMONWEALTH OF MASSACHUSETTS
��n `�.. ..--.-..OF.-.-..-.
Appliration for Big oii al Works (9jan trurtiun Prrutit
Application is hereby made for a. Permit to Construct ( ) or Repair ( ) an Individual S wage Disposal
----------- _4
ocation-Addr 6�/ or Lot No.
..... ......................................... ........ ... ......--^----..................
caner 7 6 Address
....................... ...._._.._ ,..,1, ....................................................................
Installer Address
Type of uilding Size Lot
__ a.:Sq. feet
U Dwelling—No. of Bedrooms.......... ............. .Expansion Attic ( ) Garbage Grinder
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dGaO e fixtures•....................................•-------•-------•----••---------•-...---•----------------•------•-• �.............----------------
' ,�.�—
Design Flow...._..... �_;�_.gallons per person per day. Total daily flow..........•_.._ gal
W -- --•--- •-•-•----- Ions.
WSeptic Tank—Liquid capacit�(bO Cgallons Length................ Width....... Diameter................ Depth................
xDisposal Trench—. o-- ------- ------- Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No...... ameter.................... Depth below inlet..........-.---- T1 'ng area..................sq. ft.
Z Other Distribution box ( ) Dosin tank ( )
Percolation Test Re Performed by-_ . :-.__ itPit ......................... Date....� ...........................
Test Pit No. 17 Y___minutes per inch Depth of fi .................... Depth to ground water........................
(x Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water._ ....................
a'
-• ------------------- e - ........... -••-•••-•-_.... ........•....-•....--
. .:_ __ ._.O Description of Soil---- - ..
V -- ----
W
UNature 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 iI':L;•;. 5 of the State Sanitary Code— The undersigned furthe a rees not to place the system in
operation until a Certificate of Compliance has been iss b the board o
Si d_ ............... !U.....11. _.
Date
/�
Application Approved BY { .... r..............••-•.•----- t! -�1".. .........
Date
Application Disapproved for the following reasons----------------------------------------------------........................................... .............
--------------•--------------------.......----.....----------...----..........--------------------------•..--•----•-------•-----------------------•---------- ...........................................
Date
Permit No......................................................... Issued-.. /� -
THE COMMON EALTH OF MASSACHUSETTS
BOARDOF HEALTH
Appliration for Disposal Works Tonstrurtion "trutit
Application
is hereby made for u Permit to Construct ( ) or Repair ( ) an Individual �wage Disposal
System / �
` or Lot No.
Location
.......................................................-- --
.o.�r `7 Address
/
I nstall e, Addres s
Type m6Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.............................................Expansion Attic ( } Garbage Grinder
Other—Typeof Building ----'-------- No. of persons............................ Bbmvery ( ) -- Cafeteria ( )
04 Other fixtures
^� -------_----_----_-----'--' . ��~'
Deo6/o F�n�' per person per day. Totaldu�v8onc_._ ---' .
04 Septic Tank—Liquid Length................ I}iaoetec—.---.-' Deoth................
W Disposal Trench--No..................... Total Total f t.
Seepage Pit No ............ ....... Depth below inlet......x ~~ —'
ure�_--__�gjt.
� Other D�tc� zdoobox �Percolation Test Bet I �X/g
------- Date
m D �--_—T�s 9 �0.
�� � 6 Db f v —.-'----_.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.. Depth togroundwater
u1 ................ '77, P
�� --.-----.---------_.---._---_---.-------_-_--`--__--------------_----..----�-�-----------'. ^
(� Nature of or Alterations--Answer vv6eoapplicable-_-----.-------------.----^'`-�........................
........................................................................................................................................................................................................
Agreement: ,'
The the utoredcacr�cd in accordance with |
the provisions of TITLE 5 of the State Sanitary Codc—Z6eondersigoed further agrees not to place the system in
operation until u Certificate of Compliance has been issued bv the board ofhealth.
---_-_ ------------------
Date * |
�� � �
/�}�,�uovu Approved /,y-- 'X���-��'��'-'��»��-`
Application Disapproved for the following reasons:.................................................................................................................
------_-----'--..---------_.----------_---------'------------------_--_---'---_-.-.---_----------
"at"
Pero
Date
THE COMMONWEALTH oFmAssxonoSsrrs
BOARD 0.
T�HVISA Y, That the Individual Sewage Disposal System.co'nstTucted AIr
or Repaired.
ell
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has been installed in acco da ce wi li t e provision of TI 5 of The State,.Sanitary Code as described-y'n the
THEISSUANCE OF THIS CERTIFICATE $HALL NOT BE.CONSTRW AS A GU
#RANTEE THAT THE
SYSTEM WILL FUNCTIj?.Ij SATISFACTORY.
THE oowwomvvsALrx OF mAssAc*ussrrs
| BOARD ��U� LT�� |
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