HomeMy WebLinkAbout4650 FALMOUTH ROAD/RTE 28 - Health `h4650 Fal'moutlif Rd:k"- � e T
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LOCATION SEWAGE PERMIT NO.
5�6 50
V'i L L#A G E
Gofu/T Aso
INSTALLER'S NAME & ADDRESS
Jr-DsG Phi DuAa-/c
/4 fil l ow /%1
® U I L D E R OR OWNER
To 4A/ IyG SAVNG
F= ,�Gnrtis �'9A.
DATE PERMIT ISSUED Ll_
DATE COMOLIANCE ISSUED _
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A T ION ` S E W A G E PE RISIT NO.
dw
VILLAG "
IW T LLER'S NA E A ADDRESS
d°s UILDE R OR 0 Nvl
DATE, PERMIT ISSUED
DAT E COMPLIANCE ISSUED � ��
a3
14s
FP ........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH OOS-CO`Z.
...........................................OF..........................................................................................
Appliration for Dhip al Workii Tonotrnrtion Prrutit
Application is hereby made for a P rmit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
system t:
.....1 :s'o..... .._27k ..............
--- ------.---.
ocation.Address or Lot No.
• .. .... ........ . ................ ._...._._......._.
wner Address
W .................... ....... .. .. ... ........................................... ....•-..................... ....•--............._......................
Installer Address
QTyp of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedroo .... ................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building o. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ...•-• ••-•--••-••• -••. ............•••..................................................................... ---•---•---•---•--V..........--•......------••.......----•
W Design Flow.................................. .......gallon per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter.------......... Depth................
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 ( )
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........................
04 ...........................................
.......
•...................
........................................................••-....-------•-•----.........
0 Description of Soil......................................................•--...........---•--••---•-••-•----•-•-----------•--------------•-•-----------•-...........•----••--•-............
x
w ....•-----------------------••---••••••••••-•••-•••••--•••-•-------...------......----...•••-••••••....••-••••••--------•---•----•-•--------•---••••---........•---••---•--......-----•••-------------•-
V 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 iI'L U 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 dye board f ealth.
'i gned•• .... -I. -• ----• •-------
ApplicationApproved ..... ...... . ................................:...........................---•------- ll---D ............
Date
Application Disapprov for a following reasons-------------------•------------••-----------•------------------.................-------------••••----....------
.......-•-----•.....................•----•---------------.....---•-----------........................-•----•--•-----------------------•-------------•-------------------•-----------•••-••••----•--...._.
,
Date
PermitNo......................................................... Issued.......................................................
Date
a
1
A
No�......e....... ....... Fss.._,..........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........ .. ..................OF......
-..-...............................
Apliliration for Eliipos al Work,; Tatuitrnrtion ern it
Application is hereby made for a P rmit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System t:
/� o Vet
location-Address or Lot No.
21 7
............. i..:. ...... _..______________•___^__......._.._........^-••-........_..._
caner Address
W c ...........%
Installer Address
d Typebf Building Size Lot............................Sq. feet
U i
Dwelling—No. of Bedroo LL...... ____ ____ _._.____.__._.__Expansion Attic ( ) Garbage Grinder ( )
� Other—Type
fixBuresi>l......................-•-• .........................................................................................................................
_..-•------. .__....----......(._..>.
P I yP g P ( ) Cafeteria
d
w Design Flow...................................t______gallon 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 ( )
Percolation Test Results Performed by..................................__-_-_---------_•-_-_•_•••-••-•__-_•____ Date........... ............................
Test Pit No. I................minutes per inch Depth of Test Pit_.____.__._________. Depth to ground water.........................
G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
0' ...
••_••_--------------------------
•.....
_••••-•••----------
•......
_----------------
•...............
................
_-.....-------------------
•..............
0 Description of Soil........................................................................................................................................................................
x
U ------------------------------------------------=•_-•------------------------------••-------•-------•..._----_-----•----------_--_---_----------_-_-------------...._.....--_-•••••-•-••_-_••-••-••-_-•-
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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee issued by board f iealth.
ned./=:..dt^,
................. ----•-•---•--_...._. =
Date,
Application Approved — .._..... :�________________ .. •__• §=.
Date
Application Disapprove `for a following reasons:...............................................................................................................
----_---_•••.............................................•_•_-•_-••_._.._.._•--......._..••••••............_..........___•_•-_-_._...•--••••-•-•-•_-_•_---___---••••----•--__.----•-- •___.._...-•-
Date
PermitNo....................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
Trrtif iratr of Tomptittnrr
THIS IS_TrCERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
-'" .
-_ _ -
has been installed in accordance with the provisions of TTLF 5 of�T}�e,State Sanitary Codas �scra�bed in the
application for Disposal Works Construction Permit No.. -��______-�._I__��_______.___. dated_-- ��_ _..6..__..____________________
THE ISSU CE F THIS CERTIFICATE SHALL NOT BE CONSTRU AS A GUARANTEE THAT THE
SYSTEM VIAL FU�TION SATISFACTORY.
DATE �� -_ ... -_---....-•••---••.............. Inspector..... .. .....--------------•_•_-•......._....__.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
17lpOF......................................................•---•--_..._..._............... 7 0
No. ....:................ FEE...:....................
Bilivolitt1 ork��on,otrnrtion "permit
Permissionis hereby granted u : �. ._.....-•---••------•------------------•-•----••--•-•------------•--_------.......---_-........._..........-----
to Construct ( )/o r Repair an In)'n eal Sewage Disposal System
atNo.................... ..... =-----••-•-••--••••_••-••----__--•---------------•_•--••---__••-----_••----_---•-•-__•••-•_-••••------•_•-••--•_-_...___.......
Street
as shown on the application for Disposal Works Construction Permit No......... _----Wed..........................................
A.4
C rd of Health
DATE............................................ ...........
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