HomeMy WebLinkAbout0077 SMOKE VALLEY ROAD - Health ?�
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LOCATION SEWAGE PERMIT NO.
VILLAGE
1 •
INSTA L.LER'S NAME & ADDIIESS
�To Lj 77 JP� �I '
0 UILDEIII OR OWNER
o v a .
DATE PERM T ISSUED
DAT E COMPLIANCE ISSUED /0_ 7
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of // ,
. �l i -�}� yit 9 `-+�7
No
THE COMMONWEALTH OF MASSACHUSETTS
z3 BOARD4F HEALTH
r.
Appliration -fur Uiipuiittl Workii Tomitrurtiuu jJrrutit
Application is hereby made for a Permit to Construct '�) or Repair ( ) an Individual Sewage Disposal j
System at: S
80
Location-Add ss or otL Now.
.V.1SZ _. 119.r4_—.........- ,-` ? '1IG�.l1.�.LL .�C'�11�1�----------
Owner L"__ .. Address y�
W
-• -- .... A �
Installer /eN AddressS
UTye of Building �� Cr s Size Lot____ ......._..__.... eet-,
Dwelling—No. of Bedrooms....." --------------------Expansion Attic ( ) Garbage Grinder ( fir
aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
dOther fixtures . Ar r-"V.:-----------------------•-------------- --------•--•---------------------------.---•--•-•-------
W --Design Flow._._.__..�G.__.. .__._gallons per, xi per day. Total daily flow________________________3.. __.._galloons.
W l/Septic Tank—Liquid capacity j_f'157qgallons Length------ .._.. Width----5Y__._ Diameter----.----------- Depth.....1A,
.....
x Disposal Trench—N ---------------_-- Width____..___.____-__ Total Length--.-._-.____.. -_--. Total leaching area------------.._ ....sq. ft.
Seepage Pit No________ __________ Diameter......1�-------- Depth below inlet......�_.-_._.__ Total leaching are, ---�-_.sq. ft.
Z Other Distribution box (k-�_ Dosing tan ( )
aPercolation Test Results ss erformed by---------#...._!4`��!!........-------- ------------------- Date----- 7_ ._..
minutes per inch Depth of Test Pit...... ._.._-- Depth to ground water...---_
Test Pit No: 1______________
Test Pit No. 21 e '.minutes per inch Depth of Test _____ Depth to ground water-_.___----__.--_-_---
---------- = -•--
O Qr . .
Description of �So�l __.__._
x --------
---------------------- -
W
•.--
UNature 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 health. lj
/ ned. =
°-------------•-••--------------
y Date
Application Approved By--•-------- / �r ` 1�_� .-_7_ _...
Date
Application Disapproved for the following reasons:_________________________________________L:._._______..____...._.._.,------------------------------------------
i
Date
PermitNo......................................................... Issued........................................................
Date
—-- -_- _.__Y ------ - - ---- - -------t=---------------------
• -7
6......................... Fps.
THE COMMONWEALTH OF MASSACHUSETTS
t BOARD� F HE LT
S,7,� X / e
............... ... ...........0 F..................................... ------------------------11-1............
Appliration -for Uhipiial Wo!!rk� Tomstrurtion Vrruift
Application is hereby made for a Permit to Construe ✓ or Repair an Individual Sewage Disposal
System at: A/.
V
................................................ ..................................... .................................................................................................
----- • --- --------------------L--o--r-ati-o-n------A---d-d--reGssTA-_- 7ZED - '........................ ....... -----------.......................�..../.\...V.._..C...'..L.y..o
...-..L...E.......I
.C...O....N......3
n4 �ss ..............
.................................. .........47----------------- ............ .....
-----X-C`
Installer Address
Type of Building 71�40- Qf
14 — Size Lot----------------------------Sq. feet-
U
—No. of Bedrooms-------------------------------------------- Garbage Grinder (Dwelling Expansion Attic G�
Other—,Type of Building ---------------------------- No. of persons_-_____---_______----___--_ Showers ( ) — Cafeteria (
P4 Otherfixture -_--------------------------*enr4e:K-ti�!----------------------------------- -------------------_---------
'3. . .... ------------------
Design Flow.......L,------------ -------gallons per per,day. Total daily flow-____-___________.--_---_---__-_---.------.gallons.
1:4 Septic Tank—Liquid capacid-5 --gallons Length____Ir------- Width.-- ----------- Diameter__._....__..____ Depth....___'__......
--------- ----
Disposal Trench N. .................... Width----,-------------- Total Length______--__z Total leaching area__,__6---(g_-�-----sq. f t.
/&- 6 ------ -
Seepage Pit No_____________________ Diameter____________________ Depth below inlet...._.____........_ Total leaching are--1-_--------------scl. ft.
Other Distribution box Dosing tyak
Percolation Test Res lts ,. �__Performed by---------- -------------------------------------------------------------- Date------------------- --
" I 4;j- I A
Test Pit No. V _........minutes per inch Depth of Test Pit------------I------- Depth to -round water-_2-
TV ---------
Test Pit No. 21_,_a......minutes per inch Depth of Test Pit.................... Depth to ground water---------------------
4:4; --------------C---
0 Description of Soil----
------------------------- ......... -----------�--j--------;7��--------:�-------------- ------------
Zt----7 ---------0...I......
--------------------------9.............
U -------------------------------------------------------------------------------------------------------------------------
-
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs o �Alt6rations—Answer when applicable--------------------------------------------------------------------- --------------------------
----------------------------- -------------------------------------------------:-------------------------------------------------------------------------------11----------------------------------
Agreement:
The undersigned agrees to install the aforcdescribed Individual Sewage Disposal System in accordance with
thpp`r`o'-v'isions,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 health.
Signed
-------7----------------T-----------------------------------------------------7.- Da-t-e7--�?-------
Application Approved By---------- ..........i-I-----------Z//-/I . .......... -----------------------------------------
Z Date I
Application Disapproved for the following reasons:.......................... ---------------------------------------------------------------------------------------
.................................. ......................................................................-----------------------------------------------------------------------------------------------
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTM
........ ...........0 F...... ..................I.....................................................
(11rdifirate of Tomplialarr
THI.f /-,S, IS TO ERRIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
b,.......A.tL�L... ..........62� --------------
3 _--------------------------------- .................................... .............X.......
Installer
at 0 y l' �"// -// r d- /- I&Z
------------------------------------------- ................------------------------------------------------------------------------------------------------------------------------------
has been installed in accordance with the provisions 2 .3 X 1AAW State Sanitary Code 4sjescribed in the
7
date ........... 7--------------
o application for Disposal Works Construction Permit ------------------------------------- d----- Y
THE ISSUANCE OF THIS CERTIFICATE SHAL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-------- -------------------_-_----------- Inspector--------
----------------------r.........................................
le 4V4_1�d4l'_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Ix4
................................... OF............. ......................................
iNo...............K"Z FEE........................
7
Permission ��e,eby granted________- .......6 -V-----2 -------------------------- -------------------------------------------------
to Constr Ct or Repair an/Individual Sewage Dispo,4a]'Sys'tem .......
atNo....... ..........L.................................................Street-------------- -------------------------::;7- ---------
as shown on the application for Disposal Works Construction. Permit,/N&_�;------------el Dated___Z)__.
----------------7-------7----7'
................... ................................ ---------------------------
Board of Health
DATE................................................................................
FORM 1255 HOB13S & WARREN. INC.. PUBLISHERS
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