HomeMy WebLinkAbout0250 SMOKE VALLEY ROAD UNIT #A - Health (5) �"D Srrla k� r/a L L e c�i Ito ace/
go'S 77ir
NO. ~• / -�-.:.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
... .�!✓.2.'1..........0F....:......... ......_........ CL"l
Appliration for Uhipaaal ork�orepair
.�nitrnrtiun anti#
Application is hereby made for a Permit to Construct ( ) ( ) an Individual Sewage Disposal
System at
� �._._ ..�... L: : . �'n_........�....-�s �=�..��......-•--�• - -
............ �_....e. S
�� L Uon-Addres pp oyt No f` ..................
W2;Aner, Add ss
W .............................
Installer Address
Type of Building Size Lot041/_!r!AP.Sq. fee
Dwelling—No. of Bedrooms....._.. ..............................Expansion Attic Garbage Grinder
Vylb
'4 Other-Type of Building ............................ No. of persons............................ Showers — Cafeteria
dOther fixtures ------------------------•--------- ` `�_-----------------------------------
allons per person per day. Total dail flow..............r__
W Design Flow..-..---•-•-•--�-"-�- ................g P P P / Y• ry ------ •-----gallons.
WSeptic Tank—Liquid capacity .t?Pgallons Length.... ._.... Width---6--------- Diameter________________ DeDth_._..?____._..
x Disposal Trench—No. .................... Width....,......._..__..Total Length............... Total leaching area... __. sq. ft.
Diameter.... ........... Depth below:inlet___ .._..... otal leachingarea. �'_/....s ft.
Seepage Pit No......J---- P ,�/ G q
Z Other Distribution box (�) Dosing nk 0 '�'' ;3Y�
Percolation Test Results Performed by.... ...............
�... __.. / _... ` ------•. Date........................
Test Pit No. 1....ee-------minutes per inch Depth of Test Pit.......6......... Depth to ground water-_ --Y-®_........0•
Test Pit No. 2................minut k7per inch Dfpth of Test Pit.................... Depth to ground water_______-_•_.-----_--____
A! �;a� .......
0 Description of Soil_/�,f � ¢:............•--•----•--•-----....:----•--•----......_......_....--
x ....... � . ---••--••--•-•-- /`' ---••-......-•................
V _ /J .................................... -
W •. .....................-................................................................................................................................................................................
UNature of Repairs or Alterations—Answer when applicable....:................................................:..........................................
--------------------------------•--•------------•----------•---------------------------....--------------•--•-----------.....---------------•--.....---•--.............................................
Agreement: i
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT Z' 5 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./�
Sign .. --••- • . .•.��.....� . 11:.................. ................................
Date
Application Approved By..... . •-- .... _ ... � !/� -`9' - ....=........
Date
Application Disapproved for the following reasons----------------------------•--------------------------------------------------------------------------........._
....-•------------------------------•-----•--•--•--•---------.....-----------------...........•.......-----••-•--••••••--•-•-••---•-------••-----•-•--•-••-••-•---•-•---•------•------•-•----••---------
N Date
PermitNo......................................................... Issued -L `�` ------------•----
Date
`w_TKE COMMONWEALTH OF MASSACHUSETTS(
r
-=-' BOARD OF HEALTH
1 , S_..
r .. ..'1...... ..........OF.............. ............................
Applira#ion fur Bispuu �1 nrk� Cnl�n�#rnr#iun �rnti#
Application is hereby made for a Permit.to Construct ( or Repair ( ) an Individual Sewage Disposal
System at: ��� #
..... •-n---•• .. ...... ......... X -----------•-• ...............................................................- .......
4 L atAon-Address t No.
���� r ...!'s >ry » :5 / �.
.._- --•::................ ....._......_.._._.............._..._ _.........._ ._............_..........._... ...... ................��,/ p
Owner' Address Y
wr._-c-vy - .... ..
Installer Address
.Type of Building • � Size Lot.�6.:/4.:�....?�Sq. fee
U VVP
Dwelling—No. of Bedrooms-•-----------------------••---•-__..........Expansion Attic ,��)� Garbage Grinder
PL, Other—Type of jBuilding ............................ No. of persons.............................Showers ( ) — Cafeteria ( )
aOther `fixtures,...................................................................................... p „�...... . ......•-•-
wDesign Flow............... t�_._..._.. ...____gallons per person per clay. Total daily flow...........,_... _____..____.____________.gallops.
WSeptic Tank—Liquid capacit}aJ��?gallons Length---10_..... Width...l?___...___ Diameter................ D th................
x Disposal Trench—No..................... Width.................... Total Length...............r--- Total leaching area.. ._........sq. ft.
Seepage Pit No......./........... Diameter.....! ...........kDeph��)below inlet___, lG'_�_s_.___.jotal leaching area..C7 ..!�..sq. ft. .
Z Other Distribution box (�) Dosing .�>
aPercolation Test Results Performed by.__.� ---- � 7"ark a,.................... Date...•._.......__.._1 f6__
Test Pit No. 1... .......minutes per inch Depth of Test Pit.......-•-•......... Depth to ground water________________________
Test Pit No. 2.......:........minut per inch Depth of Test Pit.................... Depth to ground water........................
2�
ODescription of Soil�-f� ---��•'----•-----------.11-••-• --• ------------------------------------------------------•---------------•
c,
w
UNature of Repairs or Alterations—:Answer when applicable..........................v_.._____..___..................`____.__..._.....:.._..............
e
a
Agreement: e
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with l
the provisions of TITTLE 5 of the State Sanitary Code—.Theundersigned further agrees not to place the system in"
operation until a Certificate of Compliance has been issued by the board of health.
qq Sign dy, -,�-//fJ -----------------------•--------___--__--._--••-• - --------------------------------
���irLwn:r _._.L.. Date
Application Approved B G J
Date
Application Disapproved for the following reasons:................................................................................................................
••----•------•••-•-••--••--•...•--•---•-=-••--•-•-••••--•---•-----•-•-•-•--•--••----••-•••-----•-•---••••--•.............•••-•••--••----•-•-•---•-•---•-•---•----•••---••••----•-.........--•••••-------
Date
PermitNo.......................................7....---•--------.. ' m Issued........................................................
Date
THE COMMONWEALTH OF MASACHUSETTS
BOARD O <HEALTH
.. OF...........:...... .........................
Tn#ifirate of Tomplianr
THI IS 0 CE FY, That the Individual Sewage Disposal System constructed (,--) or Repaired ( )
by G �-g. I. ---•- --
................................
staller ly v = :`
at., ?--- �
has been installed in accordance with the provisions of TI ff The State anitary Code as described in the
application for Disposal.Works Construction Permit No.`..............l.._7p_......... dated.....7_.�_` �'._ _ ................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM -1lYILL FUNCTION SATISFACTORY. I? �
r ----••••••-•••--••-•••--•....••--_--•-_. Inspector.............••-•• -
DATE._...___ = - 1..���...7 C
h
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 01 HEALTH z
OF.......... s..� C - ...._............. �.
No. .....1 FEE-•- -`•5--•--=•-----
i r� ttl #r ion Fermi#
Permission ss ereby granted.-••_•� ...•• �...... -••• '-!®----•-•••--•...........� -1____________________-
to Cons r (" or Re r ( ) an In S rage Disp al SyJ =-�___
Street
as shown on the application for Disposal Works Construction Perm-I .............
4eak •-•----------------Board of
DATE.....,- ...../-/"2_..�0................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS _
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1 g FRANK � rX� FRANK ul
CONERY U CONERY
No. 6232
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PLA rN OF LAND
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FRANK CONERY S THE TTOR ST.
�G _ _ �. - -• -t- A a HYANNIS, MASS. 0260t
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/0 /2?1 1 / '-s 6 d/" i(• � .'1 lye-. SCALE 1 1N -3opt. 71Z8/78
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