HomeMy WebLinkAbout0191 MONOMOY CIRCLE - Health (2) ����I .��r�a� �° r C�a�"
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No......................... ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
12...............OF..... .. .../ �+'�=� L.�'
Appliration -for ]iiposttl Workii Tomitrurtioo VProiit
Application is herebymade for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
G I �---------- 1 �------ --�------------------------------------ -----
v
---._.... .------
�sation•Ad ss r Lot No.
�J/J� -----•••••--•----•---•---•-•--
Owner %��r� /wd!��ddress
WtTf --
a ��
� Installer Address �
UType of Building Size Lot.,...Q__ _____......Sq. feet
Dwelling—No. of Bedrooms-_.__ .............................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures ------------------------------- --
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacit�� gallons Length________________ W' tl _.__V..-.,D meter_--.-_---._--_ Depth...._-.--_---
Disposal Trench—No. .................... Widtli- ota- Le _' otal leaching area..../..._--__.-._-•_•sq. ft.
Seepage Pit No_____________________ Diameter' .._. Depth below inlet. ....._ Total leaching areal���....sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) e)�v �� t 7 7 G
Percolation Test Results Performed by----------------------------------------------------------- -- Date........................................
Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water........................
rX, Test Pit No. 2............_---minutes per inch Depth of Test Pit.................... Depth to ground water__.__.--___-_-_.._......
G -----------------------:-----------_.------�i----... •_. « t-._.
- --..
Description of Soil--,�" ------ ----------- �-•---•-�{s-s� --- �/7'e�'`�----------�------~�- `�- -- -- - --
x -� ----- ---
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 rther agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board r
ealth.
ne --------------------------------
Date
Application Approved By--------------- - ---- --- ------ --- --- C� 6r=• - �®
Date
Application Disapproved for the following reasons:-----•--------------------------- ....---._....---.-•.........._...._..________.._..............._..._
---------------•-•-•-•------•--------------------------------------•--•----------------•-...........................................................•-------------------------------....................
Date
Permit No........................................................ ate
Issued...................D ...------------------------•----
Date
C?) g. t�
No......................... Finc .....fie
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
� r�< / !� .
Applirtttiun -fur Ii,4puiittl Morkii TottMrurtiun Vrrtuft
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: _
% :........ / �G................... ...................................
L,ocation-Add ss t _ or Lot No. --
jZ
�—
= :
_ Owner Address
W
Installer Address
UType of Building Size ------Sq. feet
-, Dwelling—No. of Bedrooms..-__- -------------------------------Expansion Attic ( ) Garbage Grinder ( )
per, Other—Type of Building -------------__z:'------------ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ---------------------------------------------
W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacit�rf egallons Length_............. W, th-_._ Diameter__...___.--._--_ Depth----------------
x Disposal Trench—No..................... Width. Total Le i... ..._" _.__. .. Total leaching area--------------------sq. ft.
Seepage Pit No_____________________ Diameter_ -_-_ Depth below inlet Total leaching are,
t. ...sq. ft.
z Other Distribution box ( ) Dosing tank ( ) Jd_ ;V C 1- 7 - 7(,
aPercolation Test Results Performed bY.......................--------------------------------------------------- Date-----_------------------ ..........
Test Pit No. 1________________minutes per inch Depth of"1`est Pit-------------------- Depth to ground water.__--_-..__-.---.-_----
fTA Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..............._-___-...
Ix -------- ---------- ---------------------------------•--•- /' �, f ---
O Description of Soil___ /t���____.._-...__._�.- �r f� -
xof
---- '_�-!- Q_..�_ ..—-------------
U
w
x ---------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------- --------------------------
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 f{urther agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of )iealth.
Sig e4" `--Z._� = - r� li�---Y-
+
Zoe
l / Date
Application Approved BY o� (- 2-`7--- ---------------
Date
Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------
................•--•-----------------------...........------------ ------------ ------------------------- --
Date
PermitNo....................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........ .... .......OF........... .. . .
Qrrtifirate of f.Tontlilittnre
THIS IS CERT ;lY, That the Individual Sewage Disposal System constructed ( or repaired ( )
by.. .... !/ ------... - -----------------------
Inst or
has been installed in accordance with the visions of Ar cl XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No----.710__.._;.7_�-------------- dated-.-----_lp.-__��__y�._7.__�........
THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT TIME
SYSTEM WILL FUN CTION?ATISFACTORY.
DATE ` 7 ••---•-•--•••--•-•--- Inspector-- �e
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF EALTH
..........�..... .....OF...............�y�. ....."...............................
No........ °�• l� FEE........................
�i��u�ttl ' ur ,��un rttrtiutt rrutit
Permission t reby granted---------- ______G______.._.__
----
o
to Con stru ( or Repair ( Individual Sewage i�posal Sys m
at No.. --. / .. -� --- ----------
treet
as shown on the application for Disposal Works Const uction Permit No........ ___. Dated-------
------__ .�/..............
-----•--------------------•-•---------•---- ----
Board of Health .
DATE-------------------------------------------------------------------------------- �G--�/ ,r�_ ��� G �
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
BY DATE. c, W• SUBJECT.............................. ........ SHEET NO. s,R OF
_.. .., cf,6-
CNKD. BY DATE _ . . ................. .....,..,... JOB NO..............................78
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