HomeMy WebLinkAbout0114 MONOMOY CIRCLE - Health (2) {i'••'1" a 1F '° t3 a �� t' t..- rI t: .
.
.�N-.
a
0
f
�\ 0
YmE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
, ppliratinn -for Biti uliFal Works Towitraartion Vrritift
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
sys1/�t: ,�
—
�<�, Locan jtilc " 0 0 0.
Wie; �iJ i Address
a -----• ---------------•--- -�'------------------ --------------------------------------
Installer Address �---r
Q Type of Building t Size Lot_._fC��l---Sq. feet
U g— ..............Expansion Attic ( ) Garbage Grinder ( )
Dwelling No. of Bedrooms___._____._ ._.__._.___
a4 Other—Type of Building _.-------------------------- No. of persons.._____---__-__-_------_-.-- Showers ( ) — Cafeteria ( )
QOther fixtures ---------------------------------------------------------- --
W Design Flow-------------------------------------_------gallons per person per day. Total daily flow--------------------------------------------gallons.
P4 Septic Tank—Liquid capacit/ ._gallons Length................ Width................ Diameter...........----- Depth.--.--._--.--_.
xDisposal Trench—No. __: _-_—_ Widtlu------------------- Total Length---__-----.-___-_--. Total leaching area-------------.------sq. ft.
�D €� p Total leaching a ell._.._ 1.
Seepage Pit No _X. _____ tame er____________________ Depth below inlet__._ _ j __-.-.____.sc tt.
Z Other Distribution box ( ) Dosing tank ( ) a /C `�
a
Percolation Test Results Performed by-------------------------------------------------------------------------- Date ....
Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water...-__---.--:-.--------
Liq Test Pit No. 2................minutes per inch Depth of Test Pit------.............. Depth to ground water------------------------
-------------------------------------------------------------------------------------------------------------------------------------------------------=--
0 Description of Soil-- W-A�®-_--_ -................ ----------------------
t, -----------------------------------------•--------------------------------------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------W
U Nature of Repairs or Alterations—Answer when applicable................................................................................................ y
----------- ---•-----•----_. -----------------•--•------------------_--__.----_- ---------•------------------••---------------------_.---•--•-------•---._-•---------------------- -------- ---------
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 under ied further agrees not to ce the system in
operation until a Certificate of Compliance has been issued by th boar of health.
gne - — •- ---------------------•-------_-----
at
Application Approved. B /
Date �
Application Disapproved for the following reasons: _..----•-----------••-----••---------------•-•-•--------.....__----------------------------•-
Date
Permit No......................................................... Issued--- r` L C ate
AlTHE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
^�
. -'' ��� -�
Installer Address _.~
Type of Building Size feet
� Dwelling—No. of Be6r000`o---..���---.--_---��y�ox�n�`/\t�c ( ) Grinder ( )
aq Other—Type* of Building ............................ No. of persons---------------------------- Showers ( ) -- Cafeteria ( )
()t1jer fixtures ------------------------------------------------------_-----'----------------------._-_--
Dcoigu Flow--_--_-----'---._.gallons per person per day. Total daily flow............................................gallons.
Septic Tank—Liquid Length................ Width................ Diameter---------------- Dcpd`-.----
Trench Length.................... Total leaching area------------- ------sq. 6.
o,ucr Distribution box \ / uvvoqg tank \ / a4� ~ PC ~�vt ~ ^� /|�/��_/ . un���«���~
~~ 9crco�tix` I�uResults ' Performed by------------- ............................................................ Date-------.---------
Tcs Pit No. l__..--_zninutesprrinc6 Depth of Test Pit.................... Depth to ground water-------'
Tcy Pit No per inch Depth of Test Pit.................... Depth to Qcouo6 water.-------�
_ ' -'_-- �
ig`
`~ Description of '' .................................I-''---..---._--.--'---''_---'
�
................ - -------------------------------- .................................................................................................................................................
_---------------------'_------_-__-_--_---------_'---_--_'--_-_--__--.-
U Nature of Repairs or Alterations—Answerapplicable.---------- ---------------------------------------------- ------------- ................
| -------'--'-'----'--'---------''--'------'-----------'-------'-----------
� Tf�lundersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
. the ^ . of the State '
Code The further agrees not to ce the system in
operation until a"Certificate of Compliance has been issue by t :boar of health.
Ligne ............ -- ----- . ................................
Application Approved By-------
Ao
Dat
.4ar ea
_---�___----._-_.----_'--------7----'''--_-___-__-._-------_-_-_-'_-__---_--
'~ " ' o"�
�ero�� Date
�
�
'
THE oOwwom ` LrHmF MAssAo*ussrrs
~ BOARD HEALTH
I is ER T That the Individual Sewage Disposal System constructed ( -4160ro'oRepaired
`
^
-y
u�.
. � �����--��_�. 'e�.
installedState Sanitary de as descr;'bed in the been has accordance 'it ' �� �
�- -� w�^
DATEapplication fo'r' Disposal Works Construction Permit No.... .... ..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS , UARANTEE TdAT THE
SYSTEM WILL "NCTtON SATISFACTORY.
dated'
THE commomvvsxLr* OF wAsswc*ussrrS
60ARD OF, HEALTH
^ . � __�� �
� t ^�F ����=��.�
'' &&��� wr-�"
BoardIOU'
or In vidual Se e Dis jol.�Sys:te
to Co str .s
Stree
sj: ti --- -----
as shown on the a on on e J. _11F
- , of --l- '
' vr
PUBLISHERS-
. ^
`