HomeMy WebLinkAbout0165 STONE HORSE ROAD - Health 165 Stone°Ho.Arse YP�
O,sterville
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L0C&.T10N3 '5EW8,C4E PERMIT QQ.
IWSTQLLER 5 Qb®AE ADDRESS
D®.TE PERKAI-T ISSUE®. �- -s'
D ATE COIAPLI WI CE ISSUED ; t-.4_ `•-7 77-77777
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LOCATION 5EWMC4E PERMIT MO.
VILLAGE
INSTALLER S..I &L AE 4,-'.- ADDRESS
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DD,%TE._P._ERMIT I.S_SUED_-.e-fA;IL:_?
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DATE COMPLI &MCE
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_. .......OF..................................... ----------------------.............................
Appliratiutt -for Diiipoiiat Workii Towi#rurtion Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
1,6-!5 1 ---------•------�---------- Cf •-- -------------------------------------------------------------•-•---
j Location dd s or Lot No.
owl ` �p Address
a -• z Y._.!T! QA'Y:( _C�.L-�� ---------•--•---------•------
Installer Address
Type of Building Size Lot... -----Sq. feet
Dwelling—No. of Bedrooms............._------------------------------Expansion Attic ( ) Garbage Grinder
aOther—Type of Building ___________________________ No. of persons...__5_ __________________ Showers (Z) Cafeteria ( )
Otherfixtures -•--'b- -'----------•-••-•--••---•------------------------------------------------------------------------
Design Flow................ D __ gallons per person per day. Total daily flow___._____
W ------ gallons.
WSeptic Tank�Liquid capacity/gallons Length---------------- Width................ Diameter---------------- Depth.________-_---.
x Disposal Trench—No_ ____________________ Width......... - _ Tot n Total leaching area___-__-___________sq. ft.
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Seepage Pit No._.c_../............ Diameter_/Uv.V_.� el.w t t__ _ Total leaching area.-__--___--__.__sq. it.
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Z Other Distribution box ( ) Dosing tank ( ) C �/-7,-,
~' Percolation Test Results Performed by______________________________ ____ ltr_��e_�':______.__.__._ Date___._...__.7_"�1"�_-__
aTest Pit No. 1................minutes per inch Depth of Test Pit____________________ Depth to ground water---------.___-_-____----
fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-___---__-___-______..
------------------------------- --------------- ---
O Description of Soil---------------- -------�fcaw�f-- ctsy!-d
U --------------------------------------------------------------------------------V--------------------------------------------------------------------------------------------------------------------
W ----------------------- ------=-------------------------------------------------------------------------- ---------------------------------------------------------- .................................
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 Article NI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been sug by the board of,health.
Sign - • - ^-r- ----------------
�/ Date
Application Approved By----- _ �3 '-�' 7.�
3'r �
_ Date
Application is ovdf o n o - _ __ ._.____________.__._e • o f sn :::_--•---------------- :---- = .____ -- ......................
Date
PermitNo........................................................ Issued--- S - ..........................
Date
r>I
No....... Fig$../L/)................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
_.. .__... .... . .- -----------.OF ............................................................. ......................
Appliration -for Ui.npu.6ttl Works Tomitrurtion Vrrufit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.............•---_'----------...-------...---_--•------------------------•------------------•----- --•-'-•-•••-------'---•-------_------'----------------------•'--'--------------•--------------•--
Location-Address or Lot No.
W ............................... -----..........'----' �=-- -' -- � -----------------------------------------------------
_-----------------------------------------
Owner If'}y , Address
67------------------------------------------
Type of Building Installer Size rLot............................Sq. feet
Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ___________________________ No. of persons.--------------------------- Showers ( ) — Cafeteria ( )
Other fixtures ---------------- -------------- - - __
W Design Flow________________12^_!�______________ gallons per person per day. Total daily flow........5..��'"�_....__.__.-_...__-_gallons.
Septic '1 ttik�Liquid capacity_l _gallons Length---------------- Width._ _-.-.._.-_.- Diameter-----.........__ Depth_____--___.._..
x Disposal Trench—No_____________________ Width---------.{.._-�Tot en_t ___ Total leaching area--------------------sq. ft.
,�� ,� ---•--____--
Seepage Pit No..................... Diameter.kl�:_�__bK IJep�h 15elow I�et__�_I______________ Total leaching area------------------sq. It.
Z Other Distribution box ( ) Dosing tank ( ) ``� ' T- y-;,j - _
Percolation Test Results Performed b _______________A__ �'u!��C_.Y:______......... Date_________.�__'�.`/._"��
a Y
a Test Pit No. 1----------------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
- - -
wa ter___-_-___________-_
- ----- - '------- ------------- -------- --------•___--•_ _-•-••-- - • •---
o ,
Description of Soil-----------------0- ------------- - •-•• ..
---------------------------------------------------------------------------- -•---•------ ---••••'•--•-•-•--•-'•---_•-••-------------•--•-----------------------•--•-------._.._..••---------
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 ssu d by the board of,health.
Sign d = = (/ =-'-..........................., / ( / a j%< ...r�_ /
-1----
---- ---- ---- --
Date
Application Approved BY---- f '! f -------- ----?✓•-----...----
Date
Application Disapproved for the following reasons:...........................-....................................................................................
Date
PermitNo......................................................... Issued...................... .................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
Tutifiratr of Tomplia tr
THI I T0� R" That the Individual Sew ge Disp s �S stem c structedfor paired ( )
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Installer f
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at. •--- ---- ........................................................
has been installed in accordance with the provisions of Ar 'cl*e XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.. 7s _...2.61 .-.......... dated_-_!�-_-__S_- ',�______............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH ,I
7> L/ 7/ ..........OF........... .......4Z1-___0 ........................................ �l��'
No
..........
7 .....
Dinpgsttl or IT rc rtioat Vrrmit FEE .
Permission is hereby granted------- ,,-- __• ____ - - _.._. .... �. ^✓1..-- �r`�c-FYI :°-._ ... .
to Cons�`u�t (�or Repair ( ) a Inaivi-ual Sewage�D�i sposal ste V
at N S= 1 � � �� �/� `� - /�.- C;.l' X------------------------------------------------------------•'___
Street
as shown on the application for Disposal Works Construction emit No .... ....... .. atedS�_S.......7.1 ...........
(�DATE.--- /_-�----"--------------- 7 ............................................... -- Board of Health
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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c d.o* DATIs JOL-Y sit 19-7<
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