HomeMy WebLinkAbout0107 HINCKLEY CIRCLE - Health _ Iu�. o3y
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LOCQTIOt,l ' _ 5E\N&C4E PERMIT WO.
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IIvSTQLLERS 1J�IJlE � ADDRESS
BUILDER 5 Q &V AE- ADDRESS
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DATE PERNAI'T- ISSUED —
D ATE COMPLI W, ICE ISSUED ;
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THE COMMONWEALTH OF MASSACHUSETTS
EOARD HEALTLJ
J� ..-------.OF....... . . .... .....
I
Appliratinn -for lhtipviitt1 Works Tons#rurtion Vrruiff
Application is hereby made for a Permit to.Construct ( ) or Repair (1-15"an Individual Sewage Disposal
System at:
-- ---------------------------------------------------------------------------------------------•---
ocatio -Address or Lot No.
j•---•---._Addre-------------•-------------------
Owner
Install er Address
Type of Buildi Size Lot_ 4 ...Sq. feet
V Dwelling—No. of Bedrooms___________________________________________Expansion Attic ( ) drbage Grinder ( )
per, Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Otherfixtures Q -- -----------•-------------------------------------------------------------------------------------------
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic 'rink—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. it.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results'' Performed by-------------------------------------------------------------------------- Date-------------------------_-------------.
Test Pit No. 1________________minutes per inch Depth of "lest Pit-.-_____-____-____- Depth to ground water-..-_--_-_-.__--_._-.---
�14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-_--_._--_-.-_-_--.-___.
PA f -- '--
- .. * ----------l-----------
Description of Soil------------- ..........
------------------------------------- s
--•-•--------•--...----•--••-••..................---
W --------------- ---------------------------------------------------------------------------------------------- - ------ ----- -- - - - - ----------
U Nature of Rep 'rs or Alteratiops—Answer when applicable..--_r___ _
tea:..------ - : ----•- --- --
------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been g issued by the of health. q�
Sign -- . .... . . ��/--. _. _dZ' ,/ .wS�-_�--
y Date
Application Approved By------ �- � -- ................ .�:�
Date
Application Disapproved for the following reasons:........... ------------ •-•----••--------.......-•••-------------......_......-•••--.......•---•-•-
................................................ .................................•----•-----•-----------...---------------•-- .................................... ---------•-------------.-- ---------
,� Date
Permit No. Issued.. ( .. � � .... --.....
Date
Fga..,2a.................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEA
.. OF........ . ............. .
Appliratiaan -for 4:1.4 uott1 Marko Tonotriirtion Prruid
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
-- -----------------------------------------------------------------------------------------------
catio Address or Lot No.
-- - ------ .
Owner Address
!/ I taller Address
Type o7Bilding Size Lot_ 0._ ___Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic (. ) Garbage Grinder ( )
per, Other—Type of Building ___________________________ No. of persons---------_.................. Showers ( ) — Cafeteria ( )
Q' Other fixtures
WDesign 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 boy: ( ) 'Dosing tank ( )
Percolation Test Results Performed bY........................................................................... Date........------------------------------
a
a Test Pit No. 1________________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__-__-_______________- - -
-------------- -------1 --•----•••------
D Description of Soil----------------Q �'--------
x
V ------------------------------------ -•-•-----•---•-------------------------------•-••••-•••--••-----•••-•--•--•-•---------•---•••--.._-
------------------------- ------------------------- ---------------------------------------------- /� - - ----------- -----
..
V Nature of Re rs or Aiterati s—Answer when applicable._.._.t`>( _____ , _ : _/f•
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 been issued y the bard of health.
/, ',/ Date
Application Approved BY-----. • - - ----- ------ � � ----------•------- ......
Date '
Application Disapproved for the following reasons:.........................._________________________ ________________________________________________________•-•-
t
'�---� Date
' Permit No.......... ---•--• Issued.._ _'., f�-
-•--- ................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9f HEALTH
OF_
ITrrtif iratr of TaaniPlittnrr
THIS I ,i 0 CERTIFYIThat the Individual Sewage Disposal System constructed ( ) or Repaired (�
by •--•-• ,/�'�.u.. ....... =--------------------'`-'=---------------------------------------------....----------
Installer
at_.." ,► -- -•._ .. . -----•----------------•-------•---•---•-----------------••-------------•---___________``>..--• ------•-------..____._...--------••---------•-----___-•---
has been installed in accordance with the provisions of Article XI of he Statlr Sanitary Code as describe •n t e
application for Disposal Works Construction Permit No.""____ _Q�._I .___..____._ dated`_�_2_"_. ..4.."`.� ...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS GBJARA EE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. '
DATE f '— ( ---- � ----------•_____________________ Inspector.-��'... ....... - --------...... . .....
st, THE COMMONWEALTH OF MASSACHUSETTS
Q
BOAR OF HEA TH
/ D.. /�....OF
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• y�
No....._...-- f�:. FEE
Bit-IV a Morko nitrurtim' i Prrniit '
iq
" Permission is hereby granted----- - --- ! �-•...---•---.........•-•-------•-••• - --•••-•--•••......-••--•.
to Constr 'ct ( ) o epaiP (=4 I idu Se ag i al System
at 1-67--.-- ._. •---_..--•--•.
Street `
as shown on the application for Dis sal Works.Construction it No_ _________ ___ _ Dated__/ _� .4-~ •--.-••
(risY!_00-•- ----- -_---
�� 7 l oars of.Health
' .
DATE ---- -- ------------------------- --------------------=-----------•-•
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS -
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