HomeMy WebLinkAbout0124 MONOMOY CIRCLE - Health (2) r��( �"I���mo Gr'r� C��1�- .
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® O HEA
1" ....... OF....... .. ... �144............
AppIirttttnn for Cnomi#rurtilan Vrrutft
Application is hereby made for a Permit to Construct ( k<o-r Repair ( ) an Individual Sewage Disposal
Syst at _
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cat n-Address or Lot No.
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............................ ... °....................................................
er Address
Installer Address /
;Type of Building/ Size Lot_.� �_7 __ Sq. feet
�-, Dwelling—No. of Bedrooms__._._ --------------------------Expansion Attic ( ) Garbage Grinder ( )
P4 Other—Type of Building ____________________________ No. of persons_..________--__-_______-_.__ Showers ( ) — Cafeteria ( )
a' Other fixtures ..____... ._
d
W Design Flow__ __________________ _ g Ions per person per day. Total daily flow.......... gallons.
WSeptic Tank Liquid capacity? .. allons Length---------------- Width...__..__....._ Dia 'ter_--__..._...___-Depth__________._._.
x Disposal Trench—N ..................... W�idtl ..___.__ .___..______ Total L Tot , eac i" g area........__...____._.sq. ft.
Seepage Pit No.__--- Diameter- h below .-•---• ota ling area-_____.----------sq. it.
Z Other Distribution box ( ) ��Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date----------------------------------------
W Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water...-._______..__._--___.
�14 Test Pit No. 2________________minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
n: .......... ---------
0 Description of Soil-----------'�------ -- ----- - -------�'�= --A---------------------------------------------•----
x
V -------------------- -----------------------------------------------------------------------------------------------------------------------------------------------------------------•-----------------
W
-------------------------------------------- ------------------------------------------------------------------------------------------------------------------------•--------------------------------
V 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 iss by he board o e
Signed-_ •--- . ••-•---• --- •. ---- -- -- ---- ----------- -------------
Dat
Application Approved B7- -
PP PP Y---------------- - - ••- -•--^ -- -- - -Z�/L/�. . ,..._..._ � -� ...3E..///NNbbbate
Application Disapproved for the following reasons:--•------- •-----------------
Date
Permit No...........................................------------- Issued----�� "t.. Ze-t
Date
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD O,b HIEALZJ-1 Of
VI -OF......... . ..�........:....:.:.. ...,.....
Applira#ion -fear i_qploiial Workii Cnnnitrnrtion Vrrtuft
Application is hereby made for a Permit to Construct ( �r Repair ( } an Individual Sewage Disposal
Syst at r.
...
....................... .......1h(......
dr•�. cat7n- ddress � or Lot No.
.q.
......
........................................................
W w r Address
........ - = Installer "` +�� -------------• ---------------------------------•--•--------Addreess--- 's----------------------------
P�
UType of Build in Size Lot.../_ ____ q. feet
Dwelling'—' No. of Bedrooms-_.._ ------------------------Expansion Attic ( ) Garbage Grinder ( )
0-4-4 Other-- Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures __._...._.
- •--•------------- •------- --
W Design Flow_._. U._,_g Ions per person per day. Total daily flow___.___,__., gallons.
P4 Septic Tank Liquid capacityY-_4___ allons. Length________________ Width................ Dia eter.___...._.._____ Depth____.___.._.-.
xDisposal Trench—N- _......_.. ,:_-__: Widtl otal L T�- eac g area_____________ ______sq. ft.
Seepage Pit No..__._.. ` .__.____ Diameter_.. �_'�Depth b low ng area----- ------------sq. ft.
...
z Other Distribution box ( ) Dosing„tank ( )
Percolation Test Results Performed by--------------------------------------------------------•---------------: Date------------------------------------- -
,� Test Pit No. I-•______________minutes per inch Depth of Test Pit.................... Depth to ground water..-.-.-_-_--.-_._-._....
rX, Test Pit No. 2----------------minutes per inch-- Depth of Test Pit-------------------- Depth to round water------------------------
P4 ------------ 4.
D Description of Soil--- -- .......
-
x
V --------------------------------------
W
V 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 iss y e board o e
Application Approved By----'-�----- •-•- - = . � �Z -•---- �_�
- r tate .
Application Disapproved for the following reasons:....---•-•. ----...•-- -----••----•---•.................•---------•---••.....--••-----
.........................••-•---•-----••---------------------•-••-----....-•-•••-•••--...--•--...--------...-•--••-------•--•----•--•-------------•-•----...•••--•---------•--•--_.....-•--------•-------
Date
PermitNo........................................................ Issued..............................................--........
Date
THE COMMONWEALTH OF MASSACHUSETTS
ti. BOARD O HEALTH
....... .. ........Dc t......OF............. ..:. :.......................................
Tutif iratr of f omplianrr
THIS I O C [IFY, lat the Individual Sewage Disposal System constructed (") or Repaired
by...
+ 7e -------------- -----'---- ------ ---
Installer y
at............ ....�!----- - •--- - .4jt,7s_ _
.•------- - '--•--._...._--•••-•---••--•-----
has been installed in accordance with the provisiorticle The State;,Sanitary Code s desc -bed in the
application for Disposal Works Construction Permit o._.____ .................. dated_.._ .....j�.f. ... ...i4�............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A i AR N EE THAT THE
SYSTEM WI L JAJNCTIOP SATISFACTORY.
DATE... �� Y���------------------•-----------_. Inspector--------. ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH`
..OF..... ......•
No......... =,. FEE--
CEm1rurtion
Permiss o, is reby granted- . .----•-. .* za. ------
to Construct` ) or Repair (.- ) an Individual Sewage Disposal System
atNo......... --•--•-•---••-••---'-••--•--••••........----•---------------•-----•--....----------..---------
...� -------•----
Street
as shown on the application for Disposal Works Construction Perm' o. ---_•_ ___-__ Dated______
`. ____..._..~__ ___________ _ - ---------_---__----_--
Bo d o ealth
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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