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HomeMy WebLinkAbout0010 HIDDEN VALLEY ROAD - Health oqg lo" 0 r `f LOC_AT. 10 N PE M T VILLAGE I N S T A LLER'S NAME i ADDRESS ID�R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED _� f- \ \ / ���y/ .?� \� . �.., .� � 6�� 0 �� ��- ��� . .. FEs.3- ....... THE COMMONWEALTH.OF MASSACHUSETTS caI BOARD OF HEALTH QG8 �0uP1 .......--".... ...oF..... 6 z " e.e Appitration for Diapos ai 10orkii Tomitrnrtion ramit Application is hereby made for a Permit to Construct Ctz) or Repair ( ) an Individual Sewage Disposal System at• • Location-A dress or Lot No. .........................•» :i l? .. .. . .... .....:[Z-=T. o p Address a .................................�k.:`:::"'.._ .......................................... ........._..---------------•--•--•-----..... ....._..------..-______---------________-_____. Installer Address U Type of Building Size Lot_ ---Sq. feet Dwelling—No. of Bedrooms........ ...............................Expansion Attic ( ) Garbage Grinder a'4 Other—T e of Building _--__.. No. of ersons____________________________ Showers — YP g ---------------•--•-- P (---)-------Cafeteria ( ) dOther fixtures -----------------•------•--------------------------•--.----•-••-•-----------•------•--------=--------•--••----- w Design Flow...............55...............______gallons per person per day. Total daily flow.............___.�9c.5...............gallons. WSeptic Tank—Liquid capacity_ gallons Length................ Width................ Diameter-------__---_-- Depth................ x Disposal Trench—No_____________________ Width........i----------_ Total Length........._p.�......Total leaching area....................Sq. ft. Seepage Pit No.........I---------- Diameter........1.�.... Depth below inlet........&...... Total leaching area___ Other Distribution box ..sq. ft. Z (9f) Dosing tank Percolation Test Results Performed b �•�&4-0%. _____- :J ___ Date-_.______.. .l l d.._...-. Y Test Pit No. 1.....Z...minutes per inch Depth of Test Pit.......jlwrr!�_... Depth to ground water........... --------- Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ W -------------------------------------------------------------•-•---------........-----._......---......................................................... 0 Description of Soil________________________ __ Wx i.0_"........•••--• -•• (J ------------------•------- ._...•-•---•--••-----------•••------•-------------- 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 iITI:L 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 ard o eal Signe •--• •-- /...........-•- ....................... Date Application Approved BY !_. Q6t2 ............... Date Application Disapproved for the following reasons:-------•-----------------------------------------------•--------------------------------------------...--•---•-- ---------------------------••--------------•---••----------------------......---._....--------•-•------------------•--------••-•---------••-------•--•------------------------------•-----•-----•-••••- Date PermitNo......................................................... Issued....................................................... Date a.e! N0.� FEs. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 40 Appliration for Ditipas al Works Tonstruriion thrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at.._._.._ ... .. s' . �� . .. .. ��.� � . -•--•• ..... .......... � - . _..._.. __...... ...... it Location-Address or Lot No. ••. .. Owner Address .......... ------ ------------------------------------------------------------------------------------------------ Installer Address U Type of Building Size Lot O_-`- ...Sq. feet 1-1 Dwelling—No. of Bedrooms......-�3--------------------------------Expansion Attic ( ) Garbage Grinder ( ) pa-, i,e,­- Other—Type of Building ............................ No. of persons............................ Showers ( ) Cafeteria ( Er! + Otherfixtures ----------•-•-• •--•-----•---•----•--•......•-•••-•---••--•••-•••-•-•------•--••------------------•................................................. Desi Flow.............. '..................... 14r .-= W gn _ _gallons per person per day. Total daily flow_______________________ - ...............gallons. WSeptic Tank—Liquid capacity��t��gallons Length................ Width................ Diameter__.___......•... Depth................ W Disposal Trench—No..................... Width........I----------- Total Length_......_......F.____ Total leaching area___......._...._._..sq. ft. - Seepage Pit No---------A---------- Diameter.__.....}. .... Depth below inlet............... Total leaching area.... ` .sq. ft. Z Other Distribution box ( "') Dosing,tank ( ) } Percolation Test Results Performed by `. .. _ { `.1 .. ...-•.��i �� Date_........_. ��� ti `` Test Pit No. 1........ _...minutes per inch Depth of Test Pit_--__. Depth to ground water........ fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a' --•••---••••------------•---•-•................••••----• •-•-•••-•••...........-•--•-------......-•......................................................... 0 Description of Soil.........................._.........._.............................. 'f:.............................................................................................. 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 TITLE 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 ;the board of health. Signed-. Date Application Approved By_______. _.__ .., ................................... /Q � �&Date Application Disapproved for the following reasons:-------•------------- ` r-•--------------------------------------------------------------------------- --------------- Date PermitNo......................................................... Issued-..................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � < jq « ..........t ...............OF.... .: ".......... ........ .....�..................................... Terfifirate of Tautp' lianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (1)Q or Repaired ( ) b .................. .•••. -••--.......--••-.......----•---•-•--•-•----.....--•--•--••------•...-•----•-••--...---•-••---•--•--------••---•--••....-••----••----•-•-----•- ' 'L Installer • at-••-••••_ le........... ..1�! �� - ,, ----------------------------- has been installed in accordance with the prow' ions'o�TITLr. bfte Sanitary Code as described in the application for Disposal Works Construction Permit N _. .____.--•- dated................................................ 1 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......................:...... ............................................ Inspector_._-'a?s4 THE COMMONWEALTH OF MASSACHUSETTS }� BOARD OF HEALTH N6tA ..-.6.%V..... FEE............ ......... Diapooal Workii Tonsirion Wrmit Permission is hereby granted -------------------- to Construct (4) or Repair ( ) an Individual Sewage Disposal System at No. ...... � �j `�- 5-1- � - - I S as shown on the application for Disposal Works onstruction Permit No..................... Dated.......................................... ------------------•-------.--•-•----•-•- DATE........... 3 1 .......................................... FORM 1255 HOBBS & WARREN, INC., PUBLISHERS + t�t--- z lGt�1 ,ArZ-aac_e QU`r-u. (p r�t l..�q �=L-o\,c" Ito c 3 t�o1,0. 41,5 &PD -EQ'rIC -rA V- = 3sc)4 zoop. GGQ E,:f?D. USA- oC)o 4 At_.. I�� STvAq USA EcJOD GiAj-L-• PeOF 3Fr / z (t wALL Av c—A. _ .22r. SF" p,-T -71 QaeA \V3 .mot! � � � 1?"'�� •� � N ToT,A� -G �►��N = �1 £ L�.? Sa f '1" FPO?., 4'1 f f Z.,P . yLr fiCG©�aYkr loo tz�rr t"t�.s -2r44i1J o2SS. Cat 101 A AN DAM 4e ISE FF 6 •. {� .:tar. �.. `*� - -crr -711��.i�in.. I -F j.,.-•-"_�..==."'' It.IY.' C7 -�� -fix ! 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