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HomeMy WebLinkAbout0171 EBENEZER ROAD - Health t11 �4�N�z�R RED �6 07- o.�/.. � ... s = FR �.. ................... THE COMMONWEALTH OF MASSACHUSETTS ®AR® OF HE4LTH OF..Y ........................................... Appliration for Di-qpviial Workii Tongtrnrtinn Vamit Application is hereby made for a Permit to Construct*) or Repair/( ) an Individual Sewage Disposal .......... . _. ... , _.._... -- ..:......... .. - ----- --------- - ....... ocati d s or _o. Address a ................ .... lJCri /-------------------------- ... 2" ....---------.. ........................................... Installer Address PQ d Type of Building Size Lot _�. .... ....... feet U Dwelling—No. of Bedrooms... �........................Expansion Attic ( ) Garbage Grinder ( ) U a a Other—TyP e of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures .----•---------------------------------------•--•- W Design Flow.............33.P...................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., I ....sq. ft. Z Other Distribution box (k—`) Dosing tank p Percolation Test Results p rformed by------------ /��rt ' ....... ./�............... Date. /M -•&�1__-_••---.. a N �- - Test Pit No. lC -_-minutes per inch Depth of Test Pit.... Depth to ground water.._'&_. � (s, Test Pit No. 2.......Irnnminutes per inch Depth of Test Pit____________________ Depth to ground water...L'<A-----___. .........------------ - .......• .................. . Description of Soil------0 0......-•--•-------. -- --- �d� �,f ----- U 7-- x -------------- ----------------------------------------------�---- ----.�?? 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'TT E p 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 the b rd of healthA Signed --------•-------•--------- Application Approved By--------- �� ��---•--••--••-•-••-•-•--••. -•-•••2��---D ,�-----•--- Date Application Disapproved for the following reasons---------------------------------------------------------------------- ---------•----------------------------•--- ----•••.._...---•••••-•-••••-•-••--•-•-•••--•-•-•-•••---•--•••••-••-••••••-•--••-••-•--••-•-•--•••••--•---•••••--•------•-•••--••-•-----------•••••--•-•---•-•----------------•....----------•--•--•--- Date PermitNo............................................•------------ Issued....................................................... Date LOCATION SEWAGE PERMIT NO• VILLAGE I N S T A It ER' NAME ADDRESS �-7 - A :�z///- BUILDER OR OWNER CVC' / DATE PERMIT ISSUED T DATE COMPLIANCE ISSUED 1�� �.d r'h c'6 .. - � (J � N � � �9 �C� s• . THE COMMONWEALTH OF MASSACHUSETTS BOARD �OF H. l..� ..... ALTH r !! f � .............OF.,I. . ;�'� ,� lirtt#inn for Uhgpoii al Workii Tnnitrnrtinn ramit Application is hereby made for a Permit to Construct")-,or Repair ( ) an Individual Sewage Disposal System at: �- ✓ ,�/,,,�.wry Locatioi,ry�7,Address f` , ` ,.} (yam or LoeNoy t F �f,*' / L .... 5."�'d 3.c'f_ ....................... ._ ......1 .................................... .............. a. ... r P%ner Address -• --- ---•---- .............••. ••----..... Installer Address , d Type of Building Size Lo _..._._:_ ---.....Sq. feet U Dwelling—No. of Bedrooms.......... ....................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria a Other fitures -------------------------------- W Design Flow...........3_,.4�....................gallons per person per day. Total daily flow......................._....................gallons. WSeptic Tank—Liquid capacity............gallons Length---------------- Width---------------- Diameter---------------- Depth................ xDisposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.______..___.,....sq. ft. 3 Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area.. l.........SQ. ft. z Other Distribution box,k ) Dosing tank (, '-' Percolation Test Results Performed b - -- �`�-�����_ ��'�* � �` ...__._.. a f/o^� Y - Date Y Test Pit Iio. 2__ n....minutes per inch Depth of Test Pit_____________�_-- Depth to ground water _---.___..__._'" Test Pit No. ______________minutes er inch De th of Test Pit.. �_...:.._. Depth to ground water- _, 4'✓�"` ... P -- A............. Description of Soil '--------------------•-----•---•-•--......... 0 ......' x ------••----•-----•... •-----•--------•-•......----••-----• --• -------------------•-"----- W - ------`_" 4...-•---- +!....'.�_ ---------------------------------------------------------......................... --------------------------------------------------------------- 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 I- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beeq issued by the b Qard.of healt Si ned 01 --= - - -•-•------- --------------------------•--- .. d;-_--- Application Approved By........ ---------------------------•- --- ,�, � � Date Application Disapproved for the following reasons:---------•---•---•-•-------•-------•---••-----•-----------•----------------------------------------------------- ------------•••................••-•-•-----•---•-••-••---••--••••••--•-----•------•--•--•--••-•••••••----•-•--------•-•-•----•--------••--•-•----•••......-----------•---••-......--- -----........_ Date PermitNo...................•-------•----••-------••-------------- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOAR�D.,,PF HEALTHf ! '`..........OF.. ' :.' ................................... (9rdif iratr of Tout plianrr THIS IS TO CERTIFY, That the In-vidual Sewage Disposal System constructed kl,-) or Repaired ( ) byf ....... .! . ..------------------------ --------------- ------------•----y-- .................-•---••---•-•-----....------------ at------•--•-••-•-•-•--h�*•-........................................................... y l- ------------C -------( {a 1'--- -•---------------------------------•-----------•- has been installed in accordance with the provisions of TI' -K ` of The State Sanitary Code as described in the application for Disposal Works Construction Permit No. �_ �__.. .............. dated----.._......................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY.DATE ------•. Inspector._ ----------•-•--•--------------------•........� J_ - THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH Noe�� 3�d .. .. '.` ..........OF.....:, .. ' /IJ:..'.�. -- -••---......... FEE. - . Dispoo l Works T_ onoirurtion "permit Permission is hereby granted-___.:- Vp ... `.� ..._ � �:. _r. _ to Construct„• ) or Repair ( ) an Individual Sewage D-isposal stem,-- fP atNo................ ;" ''f '..�� � ... �......-•--t..i ,.......' ✓t`/ --------------------• ..................... f Street as shown on the application for Disposal Works Construction Permit No--------------------- DaAed.......................................... oe Bo�d� ealth DATE 7 FORM 1255 HOBBS & WARREN. INC., PUBLISHERS' y 14Ok3Amns ®N-±cif "s3 as 3 4 } , . --- a. 2L. SMd1` o.NINpZ 3M1 01."SHOWN4� .. sox.: V�'f Na 1d . SJHI' .N© tVMOMS o1V141M� Q3R 3.d$11 1 3lt31S1 . 03sOd084 3Ri- ltlN . . J�dfl � L' < , . q" N.l . <fb/..�/�y.:,�,.31,VQ /jfy "� / t3'�a.�S '� r .LN3E31o►' �1�11�� . 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' .!a Pcis r7: SEPTIC TANK D/ST. �, , .' . •.� • ,� i` "++ OBPTJy • +.1. _�.Ilk WASHED STOiYE _ ! 0 1 � s s • �i� l000 ' '" 1 i • • •.� p�0 P P/►'ECAST SEEA4GE �NYE:IRT E4 VAT/ONS /IVYFRT AT d1JJLD/iVG CJ 7.G T 6 FT D/AM x/V4lsT .SE"pTlC` T.4MK FT. SEh7'/C 7ANx ;: YlVI+ET.AI.r�'TR/ flTlOfV -$QX 9t' FT y ��ptlND ilIiTiFR TADLE rptl�4ET°D13TR/BtlTfON BOX. 45:,'q fT :SECT/AEI O� • .I.kACN r. s •4rsorsq srs9- n� iA 1?!MEi1%SJaiv =C T F I;l. .. atiiaaER of eEo�eooMs 3 ;_ •. ;. .. _. GAR9 GEL�rSMOSAjVv.,r SO/L LDG $DJL 7, ',TOTAL E?T/Nf14TEt� FLO,b+✓�__3V GAL.�DAY SO/L TEST/ SD/,L. TE.ST�,2. E,e Owow 4fACMlV4a R/rs S/OE.Ll`ACHING PER PLT 4W FT. p /�;jJ l�IFS/J;t,TS is/ITNES$ED BY=``, �•a st ,k BOTTOM L IC/I/Ida PER'PLT sQ. '�tT y f,�+: it sa f /°9!°I, 10"A /D/V,iR�4TlF�:J �9lJV�JNCH "MrA[. LEACH//VG •4REA `sip, FT. M -MV., RESERYE LEACN/NG AREAA�921�_.SQ. .FT _ MsCI Af ROaERTi yG'; p. 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