HomeMy WebLinkAbout0094 MONOMOY CIRCLE - Health (2) m"czn°}�'�'i c0e , Cent.
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Fsa .........................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR DZIC.
E001 H��q ........e a'1...------.OF: .
AvPfiration -for Bi,i uiittl Worko Tottotrurtion Vamil
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
system....... - - - ---------- ------------ ..... ......................... .'
-............
Cen f�
Add ss -o.
....... •--- •.-- ----•-------- -- . --- --•-- ------------------- --- --------------=-=- ------------------------------------•-------
O `er 'r Address
W
Installer Address
Q Type of Building Size Lot----------------------------Sq. feet
U Dwelling—No. of Bedrooms.............................. .............Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building --------------------------•- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
G4 Other fixtures --------------------------------
Design Flow........................ ...........gallons per person per day. Total daily flow--........ ..__._ . . gallons.
WSeptic Tank—Liquid capacit/dit--gallons Length----------------Width_.............. Diameter................ Depth................
x Disposal Trench—No. .................... Width . �- ------- Total Length-------------------. Total leaching area--------------------sq. ft.
Seepage Pit No...........h------- Diamete .P._ . _ epth below mle ____________________ otal. lea rin area____.___________.sq f
Z Other Distribution box ( ) Dctsing tank ( ) O /� 0/i —17 y. 0-4
Percolation Test Results Performed by------- ----------------•----•--•--...-••-------------------•-.......--.. Date-------------------------------•-------
,� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-.-._-----__-_-.__-_._..
(Xq Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water--.-_.-________....____-
P4 ------------•--- ----•---"`----------- --
Description of Soil------------------------------•••.. °-----------
x
w
x ----------------------_------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------
V NaLdre 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 NI of the State Sanitary Code—The undersigned rther agrees not to place the system in
operation until a Certificate of Compliance has been i sued by the and of ealth.
Siged---- - . .......---•-•----- ' ---•• ----------------
ate
Application Approved By........ . ... ......... ...... Z
C .eApplication Disapproved for the following reasons:......••-•----•---••--- ••------------•-•-------------------------------................................
............................•---••----••---•---------------•••------------•--•-••--••--•-••-------•--.....••------•-.........................._.... ------ ----
---•-- Date----
Permit No. Issued ,< � ...
ate
Art)
THE COMMONWEALTH OF MASSACHUSETTS
D '® E A.L H
_OF....... .... .... .... ...-- . .......................
. ppliratinn -for Ui,iplaiial Workii Tomitrnrtion Vrrufil
Application is hereby made r a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System �� �"......................................................
___ _ ___ __ ...... ___......... _•____ _____._._.._.._.....__..._ __ _...................____ J'S.
t Addr ss �,.,.Or o.
- ; �- ------------"-.. �'-- ................. ...._._..... ...__•__ __ -_ __ _- ---_•--..........._......__----_____..._.....
ner Address
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms___________________________________________Expansion Attic ( ) Garbage Grinder ( )
aq Other—Type of Building ____________________________ No. of persons.-____---__-_-------_---__- Showers ( ) — Cafeteria ( )
Q' Other fixtures _
Q -----------------------------------------•--------------------------------------------------•------------------------------------
W Design Flow________________________S.. __.__-gallons-per person per day. Total daily flow------------ ...................gallons.
9 Septic Tank,Liquid capacit� gallons Length................ Width................ lliameter____.......____. Depth..-._______.....
xDisposal Trench—No- _______________ Width._. __ _- Total Length-------------------- Total leaching area--------------------sq. ft.
Seepage Pit No........... ....... Diamete _ _ epth below inI t.................... Total lea hin area--------------- .sc
z Other Distribution box ( ) D sing tank ( ) d _ /` 0'/ 5—/7 4 tt
aPercolation Test Results Performed by........ ....................•----. ......-------- ---- Date------------------------------------....
W Test Pit No. 1________________minutes per inch Depth of "lest Pit.................... Depth to ground water-.._-_--_-__-._.-_--.---
' Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
---- .-• .......... ... .-----
O
r
Description of Soil----------------------- rat = �`
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 kI of the State Sanitary Code—The undersigned ether,agrees not to place the system in
operation until a Certificate of Compliance has been'issued by theoard f Health.
Siged. --- ---••�Z_'...•--••-. -------•-------
Application Approved By...... -i'-�.+�.--. --- .�'4--•=---- ;----------------- ---- � Ir �Y
>.. Date
Application Disapproved for the following reasons:.....................-- -----------------------------------------------•--------••--•-•-•---•--•------------•--
.>.
..................•---••----••--•-----------•--------------------......••-----------•--.....-----•-------'•-•---•-•--------•---------•-•----------......--•-•---------------------•--...............----•
Date
Permit No......................................................... Issued.....................................
...................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O 57 HEALTH
d[a+ . .............0F......... .... .............. ........
Trrtifiratr of f�omplianrr
THI I .T CERTIF , That the Individual Sewage Disposal System constructed ( Repaired ( )
by--------- - � ^�1.. ----- . all ----- �+ (� .
�� er
has been installed in'accordance with the pr'ro kons of Article i of The State Sanitary C e as described in the
application for Disposal Works Construction Permit No..._._.. --------��_------------- dated...L,40���.. Z
_.
THE ISSUANCE OF THIS CERTIFICATE SHALL.NP11E CONSTRUED AS A GUA; TA THAT E
SYSTEM WILL FUNCTION SATISFACTORY—
DATE..................................................................................... Inspector....................................................................................
THE COMMONWEALTH Of.,v4ASSACHUSETTS
BOARD F HEA-LT
�"`" . ..... ..........OF_..... . ... ... :.. .......... ..................._....+' � �w -
No. !f ------ FEE I................•
Disp aiitt Li ' Can , rnrtinn rrrmit
Permis ion 's ereby granted------ = :` '`= ---------------------------------•----
to Con t r Repai ) an ndividua Sew Di, oral System
1f
at No. (.. r ... �,y
.. .---- �..... .•--r.--- .- .
treet
as shown on the application for Disposal Wor Construction Pe • o----- Dated.... _.._ __.. , _ ....
f ....Board o Health F
3
DATE.............. ................................ A`
FORM 1255 HOBBS-& WARREN. INC.. PUBLISHERS
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