HomeMy WebLinkAbout0170 TIMBER LANE - Health (r 3
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LO CAT ON S AGEE PERMIT NO.
d # 17C .
VILLAGE
I N S T ER'S NA & ADDRESS
B U_I*LL D/EE R R
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appliration -fear Diipniitt1 Works rtMrurtivn Permit
Application is hereby made for a Permit to Construct ( ► or Repair ( ) an Individual Sewage Disposal
System at:
_.
��L/o�ation-Address f/f or I.ot N.
lfll:P7: I/�✓'....
Owner Address
....:
Installer Address 4
Q Type of Building // '' Size-Lot.- Q&�!-_A ___Sq. feet
U Dwelling—No. of Bedrooms..._.y_ 1_i" .. .................Expansion Attic ( ) Garbage Grinder ( )
Other.—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Ga. Other. fixtures ------------------------------
W Design Flow::;'........__________________.5" ___._gallons per person per day. Total daily flow._.S.34� g.._:---_--____-___--------. allons.
WSeptic Tank—Liquid capacitv_i9?�P..gallons Length______________ Width................ Diameter------.......... Depth---..--_-_......
x Disposal Trench—No. .................... Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft.
Seepage Pit No._1_ _.__.. Diameter------!�_��__ Depth belo in
--- Total leaching area.--_.--.-.-_--____sq. ft.
z Other Distribution box ( ) Dosing tank ) /�-G 77
~' Percolation Test Results Performed by._. 4'. ._ -�............. Date._1�:'/_ 7 7
,.a -- ----------------------.
Test Pit No. 1.......a----minutes per inch epth of Test Pit____________________ Depth to ground water_..._._..._..__._.......
r, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to.ground water------------------------
9 ............................ -
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O Description of Soil-------10epx.' n 4-----------------------------------------------------------------------------------------------------------------
(xj ?; ----------
--=-- - ------------- --------------------------------- --
/I��f; -- --.
V Nature of Repairs or Alterations—Answer when.applicable... � ,..._4.,_Z ��lG ._.. - .. 'f
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 begg i sue by the hoard of health.
p
�i F ----•------Ef���,-��-----•--------• - ate
Application Approved By----- �� --•---. .. ` � ---------_-- ........ D�
Date
Application Disapproved for the following reasons___________________.............•-----•-•--•--•--..._............_................--•--•---- ---•--........
----------------•-------------------------------•-----------------------------------.._..---•------------•-------------------------------- ------------------------------------------------------------
Permit No......................................................... Issued-.- = L{�....... ....... Date
.� ... .....--
� I
Date
------- -------- ---- --- 1_- J
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..._...... . —OF......... ..
Appliration -for Dinpoottl Workg otrttrtion Vrrntit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System/at:: , (J �7'`
��ocf tion-Address `/� �� Lor I�ot No.
... ri.w/�...L'!(!.'dl.F+/4? . .................................... d'!lti�'�LF' Zs.---1"-11115...
/ Owner Address
................................................a (!-r_c /•. Vf P�-•--------•-•.......................•.......... L.......•--
Installer Address
d Type of Building „ram// Size Lot.......czZ..?O v_-Sq. feet
U Dwelling—No. of Bedrooms...-_�_.:�.-t------------------Expansion Attic ( ) Garbage Grinder ( )
a, Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
g Other fixtures ----,-4t� --gallons per person per day. Total daily flow.....???................_........gallons.
W Desi n Flow.................. . .��
WSeptic Tank—Liquid capacity-.LU?T�.gallons Length................ Width................ Diameter----....._.----- Depth---.............
xDisposal Trench—No. .................... Width-------------------- Total Length.-_._-_------_-_.._. Total leaching area--------------------sq. ft.
Seepage Pit No �e��rP----.- Diameter....... Depth below inlet.................... Total leaching area_......----..----sq. ft.
z Other Distribution box ( ) Dosing tank ) v64 /1-G 77
'~ Percolation Test Results Performed by... _ l�:-_ !hz� :............ Date-_-.�2.�C- _-7.7--_..._--.
a - v
Test Pit No. 1.........2----minutes per inch Depth of Test Pit.................... Depth to ground water.....-.-..-_....-_......
h+, Test Pit No. 2................minutes per inch Depth of Test Pit..........._-__-.--- Depth to ground water...-. -._....----------
t� ..-•--------- ------------ -------•----.......--------•-•---•--•-•--.......--•-----••-•------.•.........................................................
O Description of Soil--------- �-•-----�c, -4-
x !
v -----------------------------------
---------------------------- ------------- -- ----------------------------�j---�------------------------------------
V Nature of Repairs or Alterations—Answer when applicable. ;e-;1
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 bard of health.
�-
Si ed�z 1......
g 'j r .iT�iLGGis%liTif� •-•--•-------• Date
Application Approved BY------/�f 1, /- ----- � -------
Date
Application Disapproved for the following reasons--------------------------------------------------------------------------------------•--.....---•-•-•--•--•••-•.
---------------------------------------------------------------------------------------------------------'-----------------------------------------------------------------------------------------------
Date
PermitNo......................................................... Issued...................... .................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
'Gr/d�.........OF........
. 1....................................................
(11rrtifiratr of T"Onwhaurr
TH I T CE lI V.. That the Individual Sewage Disposal System constructed (�or Repaired ( )
by •- - = •---• '
yl'�
st ller � �at----- -•- ------•�� ------ ---------------------------------••--•--•-•-------••--------------.
has been installed in accordance with.the provisions of Ot��I XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No .,�
•-----------•-------- dated....1.'./ ...7. .. ..................
THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM 1WJLL FUNCTION SATISFACTORY. `X
DATE----------- - ��-7 ......................................... Inspector------ ------ --•-
THE COMMONWEALTH OF MASSACHUSETTS
7�� BOARD OF HEA TH �s
No.......... FEE...
i� o nl "k l/ tr ton Vrrntit
Permission t ereby granted-------- VG ��..-......._ ....
to Con or Repair ( ) an Individua Sewage Disposal System y
at No.. ._. `�
�� �
Street
as shown on the application for Disposal Works Construct ion,P t N ..�._-.-_f-I------ Dated_...;1.-./... .......................
Board of He
DATE.................
...............................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
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