HomeMy WebLinkAbout0101 MONOMOY CIRCLE - Health �YhO-h 071
1 C(f rot ,
No........... •-•-- .................
Y
THE COMMONWEALTH OF MASSACHUSETTS
SOAR® HEA H
L /e��
/" ...............OF......... .. . .... .. ------- -----------------------------------------------
ApplirFa#inaa for Bigpwial Worko Towi#rurtioat Vrrmft
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
e
- --------------------- - -® ® -----------------------------
Yi Lo ion-Address or. t o.
caner Address
Installer Address �^
U Type of Building 3 Size Lot-//,6/--_ .....Sq. feet
Garbage Grinder (
Dwelling—No. of Bedrooms_________ _________________________________Expansion Attic ( ) )
Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Other fixtures ------------------------------ �.
W Design Flow...........................................gallons per person per day. Total daily flow.------_--__-_-_-_--_----..-.--.------------gallons.
WSeptic Tank—Liquid capacity..----------gallons Length................ Width................ Diameter---------------- Depth----------------
x Disposal Trench—No-____________________ Width-------------------- Total Length.................... Total leaching area_------.----...___-_sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below ' let._......_ ........_ Total leaching area.._--..-_--:.-____sq. ft.
Z Other Distribution box ( ) Dosing tank ( J%'C4i 1'`7'-7G
~" Percolation Test Results Performed by.------ -_-_:A-A------------------------------------ Date_-_-._--_-----_-----_.-.-_-_-__---_._-..
Test Pit No. 1----------------minutes per inch Depth of "Pest. Pit_----------------- Depth to ground water.__._---_-__---._-.-...-
(i Test Pit No. 2................minutes per inch Depth of Test Pit-................... Depth to ground water-_.----..-----------._..
r! ------------------------
---fir-- _ i
!T - �� �-
Description of Soil --- --- ...__..... ._
---- ----------o -- a '-_ '-... y
- ---- ------
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 NI of the State Sanitary Code—The undersigt d further agrees not to place the system in
operation until a Certificate of Compliance hAbDeenjby the board health.�'Sign -•-------- -- . -•----•-••----••--•----------------------•- ---- ----• ---�`o------
ateApplication Approved By------- ----- - ---•- = .- 7
Date
Application Disapproved for the following reasons:----•------------------•-•------•-•-•-•----•--•-------•------------------------------------.----------•--------
------------------------------------•----------------.----------•--------•---------------------------•---I-•--•--•-•-•-•--........--•---......-••---•----•-•-----------------•----------------•------•---
_q Date
Permit.No......................................................... Issued..........................................- ..........
Date
j No............& .... �'� Fmc ...............
THE COMMONWEALTH OF MASSACHUSETTS
-- BOARD OF HEALTH
Appliratinn -for 4:1,4pAiittl Workfi Tonti rurtinn Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: /�
f..r............:......................................................••....._ ....._ •_•_ _-a_••___......_.....•._._..........-_...._......._-----•--•__-----•--------__-
Location-Address L�_or.Lot No.
s r .
Owner Address
.............. ..........I.............................'..._..--•---........................._.. ._.....____ .........
Installer Address -
Q Type of Building Size �:... '.....Sq. feet
V Dwelling—No. of Bedrooms........................:...................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ---------------------------- No. of persons.--------------------------- Showers ( ) Cafeteria ( )
a' Other fixtures ------------------------------- - -
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter...---..---.__-- Depth----------__
x Disposal Trench—No- ____________________ Width.................... Total Length.................... Total leaching area-------------.------sq. ft.
3 Seepage Pit No--------------------- Diameter-------------------- Depth below inlet_..-_-_____-___-_._. Total leaching area._----.---_--___--sq. ft.
z Other Distribution box ( ) Dosing tank ( rL/t /- 7— 74
~" Percolation Test Results Performed by._..__---_•----- .................................... Date...............-------------------------
a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water,.--_--__-----_-.----.
LZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_-.--.---__-_---__-_----
1
--------------- -•-- ---------•••• r
Description of Soil----- G ........4)1. -- ---- --- - - `y ..
-�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 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 board of health.
Sign �- .. .. - , .......,r�✓..-------•--•-•----- jY-_._..
,'a 0. /-
� toApplication Approved BY-----
Date
Application Disapproved for the following reasons----------------------------------...........................................................Da.t.••--••--•---•.
.............................. .•-•••-••--•--•---•-•-•--------------•--••••••••----•-......-•••••-•------•----------...•-••--•-----•---•-••--•-----......--•--•---•••-----•------------••. ............
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF EALTH
.... .' C �......0F............. ...
Trr#ifiratr of fkuntpliattre �--�
THI IS TO %fIF hat the Individual Sewage Disposal System constructed ( ) or Repaired ( )
i
by --------- �_:
ins
— n..
f
has been installed in accordance with the provisiord of Ar 'cle I of The State Sanitary Code as described in the
// - -
application for Disposal Works Construction Permit No..._.6...._.�G�................. dated....___�__._..�.5.... 7.�,_____._.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................................................................... Inspector----------- ---•------------------------------------•-------............•-----......
THE COMMONWEALTH OF MASSACHUSETTS
1
BOARD O HEALTH
`T
No. •.... FEE._. .........
T ii#rnrfijan Vrrnti#
Permission i hereby granted----- L� -----• ------•----•----------•-- -----------•--•----•-•-••-•--•--•-•-••-----
�,
to Constr -t (v) or Repair ) an Individual Sew e` isposa ystem�v
atNo..,t.�l•-- -••---...... -Z...••••-• •• ...... - - -------------------------------
Street ' h
as shown on the application for Disposal Works Construction , ml It No._JF... _.:..___ �ated..:?..-.� ..�_ .C____....
.
Boar of ealth
DATE............................................ ...................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS :I
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BY [�qT> ;�. SUBJECT ........... SHEET NO. OF
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