HomeMy WebLinkAbout0012 MONOMOY CIRCLE - Health (2) AA
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THE COMMONWEALTH OF MASSACHUSETTS
l BOARD OF HEALTH
6 � _ yt:-.OF............... .. .................................
Appliratinn -for Mapviial Workii Tnni#rurtion Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System a • a
G� ........•�r_
Loc 0- or Lot No.
•••. ...... -- •-•---
«__OW r Address
____________________________________________
Installer Address
Type of BuildinL7 Size Lot____________________________Sq. feet
V Dwelling-Mo. of Bedrooms--------_- _____ _________________ Expansion Attic ( ) 'Garbage Grinder ( )
per, Other—Type of Building ___________________________ No. of persons________________________-__ Showers ( ) — Cafeteria ( )
Q' Other fixtures _.._-. _
d . -•--•-------_--•---------•------------•------•------------------ ------ --- --- ------ - --- --- ----
W Design Flow__ _________________ _____-_ ' ns per person per day. Total daily flow... gallons.
W Septic Tank 4-Liquid capacity/ __ Ions
Length---------------- Width_-___-__-----. Diameter_..-_..----___ Depth___________--.
x Disposal Trench—No.._._._____L_.______. idth________________ _ ength____ t 1 le iity�-rcz-r ----------.---..sq. it.
Seepage Pit No. _'/J Diameter_. ep�t. ....4"0 1 Nino, area ----------------sq. ft.
Other Distribution lfox Dosin tank
z ( ) g ( )
aPercolation Test Results Performed by........................................................ ________________ Date---------------------------_----------.
a Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water-._-_-______-__-__-_-._-
�14 Test Pit No. 2................minute per inch Depth of Test Pit.................... e th to ground water........__.-___-_____-_-
a -�--------• --- --------------------- --
0 Description of Soil------------- �� • ---------------s---------------------------•----•----•--•-•-----•-------------------
x
V
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 a ees not to place the system in
operation until a Certificate of Compliance has been issue board of
igned...... -- -- --•-• --------- -- ------------- ._._ _
Date
Application Approved By------- - ••----•. 2 Lr� f
ate
Application Disapproved for the following reasons_____________________________________________________________________...........................................
..._..---•---•--•-••--•-••..................••----•-••--------------•--...-----------•--------•---------------------------------...._•--•--•----------•._._..•-•----------------•...-.__..--------•----
Date
L
PermitNo........................................................ Issued.. /..-.___....._..-
Date
No......... ------ Fly$./-�............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF EALTH
- .--.OF............... c.-� .. ` ..--...
Appliraation -fair Ii!i wiaal Works Cnoustrurtion Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
a._........ ............ -----04
ion _
..........!.. .........................................
L., -Address or Lot No.
............... -- -- ........................ ••----
Ow r ` Address
--•----------- ....... ".............. ----------- ------------------•--•--...--------•---
Installer `Address
U Type Of BU1 lding_ Size Lot... Sq. feet
Dwelling No. of Bedrooms------------ ______________Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building _________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures _.._--
W Desi n Flow------------------------ .... . a M per person per day. Total daily flow___ gallons.
WSeptic Tank)_Liquid capacit� _., ons Length---------------- Width................ Diameter_-__-_----___ Depth_-______--_----
x Disposal''Trench—No_ ____________________ 'dtl en . h____ At
le its-____. __. ____sq. ft.
Seepage Pit No------- -------- Diameter-- ep52t Q�,C . in¢area sq. It.
Other Distribution box Dosing tank
z ( ) os g t
Percolation Test Results Performed by...._......_........_...................................................... Date-_-------------------------------_-----.
Test Pit No. 1................minutes per inch Depth of "Pest Pit.................... De th to ground water-------------------_--..
�14 Test Pit No. 2...........__...minute per inch Pepth of Test Pit-------------------- e:th to ground water__--_-_--_____-____-_
a - ---- ---••------
O
Description of Soil,-=- - - -- - --- --•- -------------------- -----------------__-_-_-- --------------
UZ -
-----------------------------------------------
W ..
V Nature of Repairs or,Alterations—Answer when applicable----------------------------------____:------------------------------------__--.-___--_--___---..
----• ------ . . ,-- ------ -------------------••--•------------------------- ------•-•---•-----------------
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Dispos 1 System in accordance with
tl-e provisions of Article XI of the State Sanitary Code—The undersigned further a ees not to place the system in
operation until a Certificate of Compliance has been issue d. board of
9
igned...... -- "--- -
Application Approved B ________________
Date
ate
PP PP Y------- - --- _
Application Disapproved for the following reasons_-------------------_.................._................._____..................................................
.................•----...---••--•---_...----••--•---••--------•-----•-------------------•--------------------•-••---•-------------...-•------•-•-•--..__..-•--•-------------•-----•--.._------------•--
c - Date
PermitNo......................................................... Issued..................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
,,,,✓ BOARD HEALTH
t:..-.. ... ..........OF........... .....................................
01rdifirate of Tomplia tta
THI IS 0 TIFY, hat the Individual Sewa Dis osal System c str ted ) or Repaired ( )
by....... , -- - -•=----------- ••
//
•� _ &.4-44-
11T ..................................................
1
at•• -.- �'Zr' las been'" installed in accordance with the provi �ehs of Articl �tt The State Sanitary CoVes des ibed in the
application forDisposal Works Construction Permit No._.__T .__7 _________________ dated_._.._. 1� ..........
THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUE AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACYbRY.'
DATE................................................................................. +
---------•----------------------- Inspector----------�--�--� � ---•-----C--------t-_...._.
THE COMMONWEALTH OF MASSACHUSETTS
BO_ ARD O HEALTH
�..... ...... ...OF............... ..........................
N _.._ FEE.../D............
........,�.—
%spolttl r �a1at r iapat Vermit
Permission s reby granted-- = -----•--- li 'LX. ----------------------------•------•-•----•----•-•-----.-.--._.._.
to Construct r fair an Individual Sewage.."DipeVal System
atNo. - J ` -• ..........................
',, Street �•
----._..
as shown on the application for Disposal Works Construction„ 'Per No. .: ._. : Dated_:::_
Board of Health
..........................
DATE--= ------------------------------------- -•---------------••----•-----•-- B
FORM 1255 HOBBS & WARREN..INC.,'PUBLISHERS - ✓,�- ,
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