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Home My WebLink About0145 STONE HORSE ROAD - Health i�� 5 one - Rzouci 0 3 v� LOCATION SEWAGE PERMIT NO. VILLAGE '1-1 5, -� t°'? r 4°'r 5 e kJ: 0-5 IL INSTA LLER'S NAME i ADDRESS III e e U I L D E R OR OWNER - DA T E PERMIT ISSUED DAT E COMPLIANCE ISSUED r � � ��\l\ 'O � \�I V i�\_ _ . . �lc� P-� � ��o �a No op - Fus.S ....�..�.... :_.. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...........OF........@G r V) S � c ------------------------------------------- Appliration for Uiipnsal Murkii Tnnitrnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair (6r an Individual -ewa a Disposal System at ration•Address --•--••or Lot No. .....,t..v.�✓��'- L�.'�t............................................ --.... caner a Address . Installer Address Q Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) pa, Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures ---------------------•---------- - 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 ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water_.-__.-..-_-__-__.------ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....................... R+ --------•---------------------------------------•---------•--------••----•--•--••-•---•-•-•-------••......................................................... ODescription of Soil........................................................................................................................................................................ W ------------------------------------------------------------------------------------------------------------------------------------------------- --------------- ---1------. ----•----...------ UNature of Repairs or Alterations Answer when applicable.------/Dvd q,�/ ,�_� ��/ �o_n_F -----�...... i_;-h?!�_4vt_g.Y----�Pk.-•-•--•-•---•----•--••-•--••-----•-•-•---••-•---------------/-••---•---•-•-•--....-•-•-•-----..._..-----------•------_-•_•--•-•-••---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of,L i: y g g p y of the State Sanitary Code— The undersigned further agrees not to lace the system in operation until a Certificate of Compliance has been issued by the board of health. J Signe ! -------------••-•----••------------ 11 l6 � Date Application Approved B �J .......................... - -___-_./__-_/.�-_ PP PP Y F ¢ / •------------------------------------••----------•--•--•---••-•••--Date--------•----- Application Disapproved for the following reasons___________________________ Date �� Permit No... Issued ` ................... Date � Q Fim..........................._. THE COMMONWEALTH OF MASSACHUSETTS .. �- BOARD �OF H�ELTH - C �-- ------....OF............. ..�. ......:pis T.'�.------------. Appliration for Dia#ugal Works Tomtrnrtinn Vantit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: �� Z -�CA�tion�Address --••or I.ot No. Pl .................... -------------•--•-- -•--•-•----••-----------------••---_- -----_-__----•--______--___-__-_----__---_---- - wner Address WEms' !...... ••-•--••... _E:...............................................................-_..... "•: Installer Address UType of Building Size Lot............................Sq. feet �., Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons______________•.____-______- Showers — Cafeteria QI Other fixtures --------------------------------------- - - W Design Flow............................................gallons.per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x a- Disposal Trench—No..................... Width.................... Total Length.................... Total leaching are ...................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....................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---__-_____-___--____--. a ---------------------------•--------------------------------------•----••-----...._--------•----------•-••--------------•----------------------------------- 0 'Description of Soil----------------------------•--••---...----------------------------•---------------------------------------------------------------------•.............................. V ....--•--•••--••-----•--------•••-------------------------------•---------------------------------•••--••-----•-------------------------......•----------------•------------•----•------------------•---- W •-------•--•------------------------------------------------------------------------------------------------------------------------- x doe; OYA <t G SLQ �r U. Nature of - epajrs 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 been i sue by the and df health. �g : � die-/ Signe . ....... ..................•--------------• -•------- -•---------------------------•-- A lication Approved B -- ',: '- .. `.. �..... PP PP Y-----.�;43" -------------------------•- --•---. Date Application Disapproved for the following reasons:•-------------------•--------------------------------------------------------------------------------......._..`. ...-.......................-............................................................................................................................................................................. Date PermitNo........Kp ___ Issued_....___I....(................•---•-•--.._..._..---• --------•------._......._.. Date .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... �'. o?.........O F.... et t/� 5 4 � le . . ................................................... Tntifirab of ( omplianrr THIS IS�TW� RTI Y, That.the Individual Sewage Disposal System constructed:. ( ) or Repaired -................-r- .:..----•----•----•-----• --'-=---•-------------••-----• •- i bY------_--•- -• y / Installer at........... L� �,---(-t..-h¢ �_ rr'.St. ...... .. ('!+"'t.►t ...1 has been installed in accordance with the provisions of TI 5. f The State Sanitary Code a d scrib the application for Disposal Works Construction Permit iV'o----_ y____-_-___ f / '� �"' Z da.ted_.. -- --- ------- -------.............e THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE,THAT THE SYSTEM WI L FUNCTIO SA TISFACTORY DATE. f r ,. inspector`° � f-' .r r •r:as' �".q; a ..eK _'"Sx'�-,,,, '*.r%; gg7v_4�.��^f'�+^". `.:r�'`^ 'Fa k<'� ri a'�S �rsFn +v,.>±C4Art., .; §z.:.n,'^, .,. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH / f f ..- 1� ®F....... .......`. a � � QU N................... FEE.. ........... _ t� ruttl r �nnt ' inn r it ,1 = �Permission is hereby granted ---------- to Construct or Rep •r 'an Individual Sewa -lsposal System at,No.:---•••-----/-"�)<-........a t)F no r ' `l"��`� ' .............................................................. Street rr as 'shown on the application for Disposal `Forks Construction Permit :_ _.__.:__ Dated-----�_- /. . 0� - - ------------- 1 r ---•--•.................•..._.......... Board of Heap DATF....... �-�--"--l)'f� , FORM 1255 HOBBS & WARREN, INC., PUBLISHERS