HomeMy WebLinkAbout0083 WINTERGREEN CIRCLE - Health i ,
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L A CAT I A N ''�''«" Ci.�c 1.� S E W A G E PERMIT NO.
VILLAGE
INSTALLER'S NAME 6 ADDRESS
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B U I L D E R OR OWNER /
DATE PERMIT I SIS U E D
DAT E COMPLIANCE, ISSUED 2S/
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No.__83-ash FEE....l..�................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
.................... .....................0 F..........................._.............------.-----------------------•-----•------------
ApplirFatiou for Disposal Works Tom uurtion Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at* _
C.%Ao&.. .----o 2- -=----------- ..........----:. ..-------------..........--..-------..._.
-L�oc�tt'ion•Address or Lot No.
.1 ._.. h�-!!1�--...... � ��' Rj ---.........f VIdel-e�...ei(c CS'--------------------•--
/' Owner �--- Addres /1"-
Installer Address
d Type of Building Size Lot.......................g
Dwelling—No. of Bedrooms........... -....- ...Expansions ttic ( ) Garbage GrOther—Type of Building ............................ No. of persons......V......_.._..___. Showers (` ) — Caf
a Other fixtures -----•-------------------------- -
-------------------------•••-----•----------•--••---------
Design Flow...:u-��-�............................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capac}ty/ gallons ength................ 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........................................
aTest Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water.........................
L% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
•••--------•------•--•-•••---•--•--•••--••-••-•••••-•...•••••••••••-••-•-•-•...............•---•--.........................................................
O Description of Soil.../_.... /--•------•.............. ........ ........... -
..........................-.............................................................................................................................................................................
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 iITj LE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has een ' d yy the o It
e ..- -/ -...- ------
Date
ApplicationApproved By--------,........ ---- !..........................•----...------._.__.............--•-- --- J' •....
ate
Application Disapproved f the f ,lowing reasons-------------••••-----••-------•-•••--•••----------•--•-••----•--•------•-•----------.....-------•----......-----
.....................•--------.._•---------__...._.......--------------------------...............---•--.-----------_.......--------
Date
PermitNo........................................................ Issued.......................................................
Date
No...zt.3.....A. Fxs...._... .................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..._........- ......................OF................--.......-.......-......
Appliration for 3liopoii al Workii Tonotrurtion Vantit
Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal
System at:
Loc tion Address or t o
------- __---
..� Owner /^' - Addres w ,;
Installer Address
UType of Building Size Lot__________________ ____
Dwelling—No. of Bedrooms............�...........................Expansion�ttic ( ) Garbage Gri de�
Other—T e of Building No. of ersons____________________________ Showers
a YP g P ( �) — Cafeter
dOther fixtures -----------------•------------------------••------•-----••••••------------•-••-...-••-•---••-•-----•---•-•------------•--....-------------•----------
W Design Flow____ 9--------•- ______._.. gallons per person per day. Total daily flow............................................gallons.
W Septic Tank—Liquid capaci _
y_r' -gallons ength................ 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. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
0i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
a • ---••••----••••--••-•••••-•------•---------••--•---•............................•-----._...--_...-------••----------...••-•-._......---------•-•------•-•-
Description of Soil........ .........
+,
V .................................-- ....................................................=-----••--•-----••-----•--•-•---•--------•••-------------•••.._..•-------••• -
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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has �een • b the bo o �thfigrfed.__. !_.___ •----•-------- --•---•- ..........Z-Xclo----./.......
Application Approved By --J--- !�' .� -•--•----•----------=------------•-----••------ a�D1
Date
Application Disapproved for the f o owing reasons---------------------------------------•-----------------------------•-•---------••--------- •------•-----_-----
....................•---.............-•---...•--.....-----------•-••.._._..--------........-------•••---•I-••--------•-----•-•------------•----------•-•--------•------•---•-----•---------••---..._...._
Date
PermitNo......................................................... Issued-----....•-------•••-••---•---
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...............................I..........OF.....................................................................................
Trrtifiratr of TontpliFanrr
THd,S,T'S PiI CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by . '�`.' Ins -,.----------------------------------------------------------•-----...._..---•-•-•-
- taller
------------------------------------------------
has been installed in accordance with the pr/ermit
s of TIT r''. 5 of The Sanitary Co e �esc> e in the
application for Disposal Works Construction No------- .�r__7__f_____________ dated__..-_ __..._.,*�--_.___-_____________
THE ISSUANCE-OF- THIS CERTIFICATE SHALL NOT BE CON�/S A GUARANTEE THAT THE
SYSTEM WIL F TION SATISFACTORY.
DATE....��.�._..�..............•-•--.....---•-•------............._. . Inspector-----_. _ •---------•--.......:•--...._..---------------......._
v
THE COMMONWEALTH OF MASSACHUSETTS
,r-�- BOARD OF HEALTH
J7 ...........................................OF......................................................_..............................
No......................... FEE---- .............
�io�roo�al� ;,� � �ono�ruan rrnti�
Permission is he.eby granted..... ____-fit-- _--- ----------
to Construct ( ;<Wepair ( .. a Indiv' pal Sewage Did -osal�ystem
atNo ...".,��yy-.,,�"��..... ...........t''4 ...............................................................
Street
� as shown on the application for Disposal Wo s Construction Permit No_____________________ ate.__._�_�._-_'.�•!� __�3__-__._-__.
�---
Board ofIealth
DATE.. .............. �1 -•--•---•----------•-----•----•--= `/
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
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5►►4,Gt-��FAMtt_Y - � BEORQoM - q 9 � cg
uo- GaQeAGE Ga�rvo�tz /� �:.1•
O�tt_�(`FLow a t10 x 3 = a3oG.Pv Z
SEPT1c TASK = 33ox15�'/• sA95G.PQ
i tJ sr•• 10 0o GAL. qS.L �' �
T tT - ►r�
. .61.5P03AL PIT UsE 1 o oo GAS_. ` •`
91, p
5%pswALL. AR-SA, a 1�o S,R M y, o'r•
150 5.F X Z•5 a 3?5 G•pp p.g ovNO,.
BOTTOM AQEA2 j�c sAF•_
-- • 17 94 '9 q4 1 0-
50 S.F X ,1. O s+
j "TdTA 1- OC.SI�N • ,4.25 C.P.D s T^w,.
'TOTAL DA I1_Y FLov�! = 33o G.Po 4 � � �
j PE2COLAT►ON RATEt (''IN VAIN OPLLG55 48'4 toe% 3 I
x saP 95
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