HomeMy WebLinkAbout0131 MONOMOY CIRCLE - Health (2) trnUnrn
THE COMMONWEALTH OF MASSACHUSETTS
BOARD QF HEALTP
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
Owner Address
Installer Address
Type of Building - Size .....Sq. feet
-----------------
Z Other Distribution box Dosing tank
-----------------------------------------------------
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 boar�of health.
Date
Date
— --'`--``-----------``-----------------`---------------'—'—`---`---
~^~
��� ���
Permit ` �
7G "S
No..---• ......s......... Fiziic r'..t.'.............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
OF. 4 ;;.
r '
Appliration for Uhgpootti Works Toustrurtioo Vrrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Location-Address or Lot No.,
. i. - . l
Owner Address
r. . ----•----------•-----------'---•�
Installer Address
Q Type of Building Size Lot'.:.:_.;_._`__`_.'�_____Sq. feet
U
Dwelling—No. of Bedrooms------- --- --------------- Expansion Attic ( ) Garbage Grinder ( )
per, Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ------------------•------------------------••-•-------------------------------------------------------------------------------------------- .........
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 inlet------_fi�nn-_....... Total leaching area.�- ---- .-_---.sq. It.
Z' Other Distribution box ( ) Dosing tank ( ) Q _�C /�l�I - T 7Co
a
Percolation Test Results Performed by--------------------------------------------------------------------------- Date......... --------•-------_-----.-..
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----------------------
--------------- ..........
1 :..:.---------•--.............. ----•----------•------'•---
x Description of Soil G`� - .� -___4 _i ....... ... .....
. .. , - -------------
,5 - _ ----------------------------------------------------------------
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. f
Signed-- - .
Date
ApplicationApproved By..................................................................................................
Date
Application Disapproved for the following reasons:................................................................................................................
---......-••-------------•---------.....-------------------------••------'•'-'-•------'-••-••--•-------------------------...............-----------------........-•--•----'--.....------•---•---•-------
Date
Permit No......................................................... Issued.---... 3' 7
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD Z HEALTH
................OF.....................................................................................
Trrtifiratr of f lootphaurr �—
T)91 1 ,(C�() C WIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by....... ... ..........�-� ..w�-±P..-------- --.----------------- -- --
�Installer
at._� .. _.___. . .... 1� . .......................-............. ------
haseen installed m accordance t h w t 41provisions of A XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No. 7G-___--�.� ............. dated... ."._1_17-7�-._-_•---.--_•.-.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WlLI._fZNCTION SATISFACTORY.
DATE------------- ................ Inspector ----------- ----- - .....
THE COMMONWEALTH OF MASSACHUSETTS
OW BOARO
No.._._.. ... .._._ .�� ...............OF........-..-...... ............. FEE ..
or Ql trurtion Vrrmit
Permission i h y granted.- - •---
to Const ( or p it ( ) an Individual vuage isposal �yste
Street _
7-
as shown on the application for Disposal orks Construction Permit ated_.__ '
= ----------------------•-----•-•-•-
4140Y0
----- -------- _-- ---------- ..................
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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