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Home My WebLink About0065 STONE HORSE ROAD - Health 5 Si-coe,N-ciyz5e. Y2d p 0 y r Y +._. Fas....... THE COMMONWEALTH OF MASSACHUSETTS BOAR® AF HEA TH I _ ...........OF........ . .... /........................ Appliratiun -fur Di,ipuuttl Workii Tunitrurtiun Vani t Application is hereby-made for a Permit to Construct (�r Repair ( ) an Individual Sewage Disposal -•--------------------- ........................................ ............... Locat' dress or Lot o er Address 1 � Installer Address UType of Building Size Lot..... ... - S feet ., Dwelling—No. of Bedrooms------------JL_______________________Expansion Attic ( ) Garbage Grinder (l—)' a4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a4 Other fixtures ------------------------------ - Desi n Flow__________� G>____________________gallons per person per day. Total daily flow.......W g -' g P P P Y Y gallons. WSeptic 'Tank—Liquid capacity_N""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-_---------------------------------- Test Pit No. 1................minutes per inch Depth of "lest Pit.................... Depth to ground water.--.---..-----.--.--.--. 44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water.-.--._.__-.__----_----- 1 --O Description of Soil--------- --_S CL---•�-=---------------------------------------------------------------- -------------------- -- ----------------------- x U W ------------------------------------------------------------------------------------------------------------------------------ ............................................................. VNature 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 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 b t e boa f h al ,Stgned !�/ate ApplicationApproved BY- ---------••----------•---------------•-----.---•----.-------------..-•--- ------------•----------- --------------- Date Application Disapproved f o lze following reasons:----••-----------------•-------•-•---•--------•-----------------------------------------------------•--•------- --------------------•-•-•-•-••-•-•••.......------------------•-----........--•-----•.....-----•---•----•-....------------•-------------••---•----- ------•----------•--•----•---•------------ ...... Date PermitNo.--•�fO----�-------------------------------------- Issued........................................................ Date Q r Fics.......� ....f .._ THE COMMONWEALTH OF MASSACHUSETTS BOARD ,OF HEALTH ,� 1 ..... ......OF. ' t- e✓1 .... / .. ........................ Applirtttion -for 43WVviitt1 Norkii C owitrurtion Vrrmft Application is hereby made for a Permit to Construct (�or Repair ( ) an Individual Sewage Disposal System.at, ! / Gov V/C/- = � ............................................� 1 -•••----••=-----• • . ..... --•••• •. •-• ••-•-••-•---••-••••... Coca ion_Address �• �,/�/ �� or Lot Nof J .. r Ji;7'ti 7' l ../��i ��r��7 � r`t/'G�f�C��JIiU�/ vl<ti ----•-•------•------•--•••••••......... ------ ....................... i �O ner J Address ------•----•------•---� ... .... Address -.................................... Installer U U�VJ d Type of Building ''}} Size Lot_.__�___________________Sq. feet U Dwelling—No. of Bedrooms-----------lam--'........................Expansion Attic ( ) Garbage Grinder PL4 Other—Type of Building ............................ No. of persons_---_-__-_-_____-_----_- Showers ( ) — Cafeteria ( ) P4 Other ,xtures --•------- --------•-----•------ W Design Flow.......... .................. .•---.-gallons per person per day. Total daily flow......�..�.__..... .........gallons. WSeptic Tank—Liquid capacity# G�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--------------------------------------- a Test Pit No. 1................minutes per inch Depth of Test Pit_------------------ Depth to ground water_.-.__--._--_-.--.--._.. �14 Test Pit No. 2----------------minutes per inch Depth of Test Pit.--____-_-__-__._-_- Depth to ground water_-.-_-_----.--------.__. ----------------------------------••-----------------•------•-•---•- ...............................•••-•-•••-••-••--•••••-----•---.......................... O Description of Soil______________ __ x U -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- W ------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- VNature 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 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 by the board-of jea* Signed........................................ GL--Ci---�------ "/ /V A Date Application Approved By--- •--- Date Application Disapproved f oi,4he following reasons--------------------------------------------------------•----------•--------------------------------------------- .....•••-•-•--•-••--•---•-------•---•-----------•---••---------------------••---•-••--•------------•-••-•----•-•••••---••.... ......................................................................... Date PermitNo......................................................... Issued...................... ................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 70 ..........................................OF.............elf....................................................................---- "TPrrtifirtttr of TlImpliaurr THIS IS TD CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( ) by... -- '------/hy--''---------------- / nstaller, Ir at --------------------------------------------=----- ............---•-----------------------------------------------------------••-. ...••- has been installed in accordance with the provisions of :Article XI of The State Sanitary Code as descl�ed in the application for Disposal Works Construction Permit No.______ C _______________------- dated.._.__._.. .: .......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ` DATE . 2/' Inspector•... ••...... THE COMMONWEALTH OF MASSACHUSETTS F ti BOARD OF HEALTH -'� �J No... -••----•- .................... ....................OF. ...............----------...----....................-----------................. --G•-� 1 FEE._.. _:.... �i��tt�ttl� rrrk� f- tr�rtittgt �rrtttit Permissionis hereby granted................................................... •----------------•--------------------------------------•--••--•-•-••--•---•-••----•---_. to Construct ) or Repair ( � ) an Individual Sewa e Dispo a ystem Ga� atNo............................................... ------------------------------- ---------....------------------------------------------------- ........................... Street as shown on the application for Disposal Works Construction Permit No..__..�..G_..�. __ Dated-------_.__.v-__� _-__-�---__..... q- �� -- Bo - lof Health DATE------ ---------------------------------------------•-- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS A -.on,cv/ LOCQTIO SE GE PER IT MO. VILLAGE INST&LLER�5 1 & A D E BUILDER 'M' I3 E ��. D D E M�( DNTE PERNAIT 155UED Db.TE COMPLI &KICE ISSUED ., — — — F-fvn(5- gel, to A rM.+.w.�w+.w-......r�.rr.w.-_..«-.-....m.w..rw�_�._rnnur•:_++w...._..rr.�.__«w an..aRi-.+..-r...-. r 4• O-L. „,;L- `��. 4 ,.fir` .� +. a io it (s ;� ` 14 F.41 J ! _ ----t---_,._..._.,.. �....�._.... ` {,.�`—►:�. Lc T h a Y ` f k9 1 - '- DO w� 40 CIA w E a F1� _ ,A! s- w 41 ` TM a 7 -77 olooll LE T If IF t . • y a E l:Uft RAM ,r-