HomeMy WebLinkAbout0111 MONOMOY CIRCLE - Health (2) l Gil ,
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALT
. ... . OF....... .............. . ...
. ....................................
App,firation lvr Biii niittl Works Cnonstrurtion Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System71
7--
Location- ddress or Lot No
--- c.... -•.........................
Eder Address
Installer Address
UType of Building Size Lot----------------------------Sq. feet
Dwelling—No. of Bedrooms-------------- --------------------Expansion Attic ( ) Garbage Grinder ( )
per, Other—Type of Building ____________________________ No. of persons..__________________________ Showers ( ) — Cafeteria ( )
a' Other fixtures
g4/--�...............gallons per person per day. Total daily flow............................................W Dest n Flow._�__�'____... � -_
WSeptic Tank iquid capacity__---------- ..gallons Length................ Width _.._....._.... Diameter----------.----- Depth----------------
x Disposal Trench—No--------------------- Widt i_.____. ._.__ ____")belt
._...._.._...___.___ Total leaching area--------------------sq. ft.
Seepage Pit No........./-------- Diameter_, ..�Hep _________ ________ otal leachingarea.._._..-____._____sq. ft.
Other Distribution box ( ) Dosing tank ( ���
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date------------------------------------.-..
a Test Pit No. 1----------------minutes per inch Depth of Test Pit-___---___._.._____- Depth to ground water..._:__..____..-_.._._.-
f14 Test Pit No. 2----------------minutes per inch DeptlL of Test Pit-------------------- Depth to ground water-_-__-..___-__._____....
9 -----•----•--------•--- ...............�f --- ----•-----
Description of Soil `-- �)-- g : �� //
-- --------------------- l AX
/ / �AV ------i -->•---- °`-------- ��- '� -�'--_- - -�C��- ------ =-------`�--- ! .�-fit- - ----y-- -f-a- --"'"�Ul
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 NI of the State Sanitary Code— The undersig d further agrees not to place the system in
operation until a Certificate of Compliance has been -ss d by the ar of health.
Signed - •--••- --•---• ---'-- =- ----...--•-------•-- ...-•--------------"--- -• •--------------- ��
Date
Application Approved B ----- •--- __.. �'!/l�j t_.` • . --..C.�7�PP PP roveY------ --
WiDate
Application Disapproved for the following reasons----------- --------------- -------------------------------------------------------------------------•----•--•-
............."--"-•-•--•--•----•-------"•--•--------------•-•--•----"-•-••--------•----•-----•"----------...--•---"-•---------------•-•-•---•---•--....---•-----.._._..-----------.._..-••--------•-•--••
y
Date
PermitNo. Issued........................................................
t Date
No......................... Fps.......:'nf..:...... �..
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
........OF........
✓..<e'.'fi?:z: lr.:<� *`"..:_f'
Applirafion -fur Difipuiittf Marks Towitrnrfinn Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System,at
A.
------- d ----------------•------- ----•--- ��- •--..._ ...................................................f � .............................................
Location Location-Address or Lot No '
Owner Address
_ _
%1 !f .../`_.'......-L�::12:,..............................................� ...'.... . Ir/I' -✓
Installer / Address
Q Type of Building i Size Lot............................Sq. feet
U �.
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons---____.._.-_-__.---_--___ Showers ( ) — Cafeteria ( )
P4 Other fixtures
W Design Flow.....-��........--__V~Q...............gallons per person per day. Total daily flow__:_......_3�-_____-_____.____...._gallons.
04 Septic Tank-Z iquid capacity------------gallons Length................ Width................ Diameter---------------- Depth----------------
xDisposal Trench—No_ --------------------- Width-------------------- Total Length.................... Total leaching area--------------.-----sq. ft.
Seepage Pit No..................... Diameter-------------------- Depth below inl t_._____�_.f.._.... otal leaching area.._..-_.__--.____-sq. ft.
z Other Distribution box ( ) Dosing tank ( ) G�
Percolation Test Results Performed bY----------- .............................................................. Date-•-----------------------------------...
a
Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water..-_-----__-_--._...----
f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......-.-__-__-_____-. -
O Description of Soil v --------- -- -- t'... ..... --
--.----- .. r.
----------- ------------------------------------------------------------------------------------------------------------------------------------------�:�Su.t
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.
Signed, A��' = 4= =-='= f- _= -�
Date.;
Application Approved B ... � C�7
Date
Application Disapproved for the following reasons---------------------------- -------- ---------------------------------------
•----•---•---------------------------------------------------------------------------••-•----------••----•----•--•-•-•••----•---------•---•---•••-••-----------......••---------...--•-••------••••-----
Date
PermitNo......................................................... Issued.......... .............................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............D`s ' ..........OF........ ........``............................
(11J.rrfifirate of (tontplinnre
THI T fIF hat the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by.----- --
n IlA
at- '' T! i. •-- ......•-•----•--•.....................•--•---......---•----...........---------•--...
has bee installed to accordance with the prov ns of A c e XI of The State Sanitary de as described in the
application for Disposal.Works Construction Permit NoW.14f.7................ dated... ZL+-_--_.'--'/.`...�
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS eGUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------ 1.. ------_yam�.------•-•-- Inspector------------------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
OF.....:.... ........ ..............................................
FEE �.............
e4tt
nitrnrtinn Permit
Permission i eby granted--� -•--. .. •----•------... t
to Construct ( or R an700, �Individual age D• .posal Sy ml T ---------
at N
Street .4"V
y/r +►
as wn do the application for Nsposal ks Construction Per 0........x..__ _. t .................................
Board of Health
DATE------------------------------- ------wl---------------- .........................
FORM 1255 HoeBS & WARREN. INC.. PUBLISHERS
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