HomeMy WebLinkAbout0213 HINCKLEY ROAD - Health a�3 141ncKl eci, Rd
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LOCATION 5EWaC,E PERMIT UO,
WSTQLLER•5 IJNMF- ADDRESS
BUILDER 'S 1 J &VAF- ADDRESS
DL1,TE PERW-T
D D.TE COIMPLI &&ACE ISSUED;
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA TH
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Appliration -for li,ipoiittl Nods Tonitrurtion Prrntit
Application is hereby made for a Permit to Construct ( ) or Repair (Pj*an Individual Sewage Disposal
Syst t
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Lo..... ddress ' ,� .........................................or Lot No.
. .........La ....... _A.. ...._. _ _ .......... ... ....................................................
er - � -_.- Address
(� Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
`4 Other—T e of Building No. of persons............................ Showers — Cafeteria
Q Other fixtures ---------------------------
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W Design Flow--------------------------------------------gallons per person per day. Total daily flow..............................._............gallons.
WSeptic "Tank—Liquid capacity------------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 ( ) Dosing tank ( )
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date---------------------------------------
a Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water..------._---.--_--..--.
I14 Test Pit No. 2_---------------minutes per inch Depth of Test Pit____________________ Depth to ground water------------------------
------. x
-- --:_O Description ofSoil--- -------------------------------------------------- - ._._ --------------------------------- - -
U ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
W ----------------------- --------
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U Nature of Repairs Alterat�ns Answer e 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 bee sued by the b rd h lth.
Signed..... ---- --=---I •----- - ------- .. - .
i. Date
ApplicationApproved By...... = = •--••-----------•----•---------•--•------•--•-----------•---------- ........................................
Date
Application Disapproved for the following reasons:--•-••---------•-------•-------------••---- ----.................-•------------...._-------------••-....._------
--•-••-•-•--•----•---------•----•-----•--------------------••-------•--•-----•-------------•--------•--------.----••----•-------•--•---------------------••-----•---------•-----••--•----------•--------
Date
PermitNo.-----------•----••--•--•---------•--------------------- Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA TH
..........................
Trrtif irate of fuontplianrr
TIHIS IS 10 C TI That th Individual S ge Dispos System constructed ( ) or Repaired (L-'j
byA-- � � � f-------------------- - ----------------------••-------•----------
at--------c .,3------ �M1 -----
has been installed in accordan with the provisions Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No..............,/0__jr------------------ dated.......��_�_l '.� ._______._._.._.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. ,
DATEl r /J--)-...-------- . - ------ -------- Inspector----------------- ---- ... -•---------------. --------
L.'l)<y/al/6t/�•c_� /SSG�:�
THE COMMONWEALTH OF. MASSACHUSETTS
BOARD OF HEALTH
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No............ ---• FEE___4.9.................
�i��o� 1 �rk� AITP. �trnr
Permission is hereby granted--- ---- - ...`�... _.__..._ '
to ConstruSj j or epair an.- ividuaal age Disposal System
at No. (�`/ •J f............... 1 jt street
as shown on the application for Disposal Works Construction Permit No----- It..... Dated....�1..-_"" ��
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DATE------. ---._. ealt-
FORM 1255 HOBBS & WARREN. INC... PUBLISHERS -
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