HomeMy WebLinkAbout0221 MONOMOY CIRCLE - Health (2)�I
No..._.. Fua......��...................
THE COMMONWEALTH OF MASSACHUSETTS
f ( �� BOARD OF HEALTH
_.....-....O F............ ..... .. . . . ....'... ..-......--.......------------
Appliratiun -fur UhiVagal Vorkii Tunutrurtiun Prruiit
Application i,s hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
ystem t
............................--------------------- --------------------
atio Address or Lot No. ,
s.
•• .................
-------------••-••------•-•--•-------•--•-----•- •--•--•-••---•---•-- s, 'I
ner Address �t
a ••----•-••---••--••-•••••-�-•- ... -••---_____--•--------•- -------------••-•-------•---•--•-----•----- -••------- 1
Installer Address '
Q Type of Building Size Lot----------------------------Sq. feet T
V Dwelling—No. of Bedrooms.-------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ___________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures _... ------------------------------------------------------------------------------
w 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 inletj._� Total leaching area------------------sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) 4 d � 7- -7 J—
aPercolation Test Results Performed by.................... ----------------------------------------------------- Date____-•-------------------------_----
a 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______. __ _ ____ ______________.. -
_ _ __ _
xDescription o 01 .�. 4 --- ----• .- --------- -
c.� `�` :_... - - ----------------------------
w ..-•• 1
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 NI of the State Sanitary Code— The undersigne further agrees not to place the system in
operation until a Certificate of Compliance has bee i ued b�toard o health.
Sign - ••••••- /-u._� 7
Date
Application Approved By-•-•-- f IY_- 7. -`7177-
Date
Application Disapproved for the following reasons:-------------------------------•-----•-•------______-____--•------------_______---------------------------------
...................•-•-•--------•--•--..__.._._....-----------•-•-----------•-•--------•-•-••-------••---...__....•------•-••--•-.__.._..---•---••--------..__.._.----------------•-------------•-••••-•-
Date
PermitNo......................................--•••-•--........ Issued........................................................
Date
No. ... •---..... ...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r� ..*—...............OF............. :.Cy2:t r
_. ._... ................................
, ppliratiun -fur BiBpoiial lVarkii Tonutrurtion Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.
Location;Address / l or Lot No.
.......................=-
Owner Address
Installer Address
UType of Building Size Lot............................Sq. feet
., Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons---------------------------- Showers' ( ) — Cafeteria ( )
fi, Other fixtures -----------------------------------------------------------------------------•------•-•----.----.-----.--------------------------•--.-----_------
W Design Flow--------------------------------------------gallons per person per day. Total daily flow................................_-...........gallons.
WSeptic Tank—Liquid capacity--_.-.--_--galiofis Length---------------- Width------------.___ Diameter_-_.__...___--. Depth-___----_----
x Disposal Trench—No_____________________ Width-------------------- Total Length..................... Total leaching area......------- ......sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inle���
Total leaching area----..-----.-___--sq. ft.
z Other Distribution box ( ) Dosing tank ( ) ®� • 7- 2.2 -7 a-
aPercolation Test Results Performed bY.......................................................................... Date----------------------------------------
,_l Test Pit No. 1----------------minutes per inch Depth of "Pest Pit._.____-_____-___- Depth to ground water_._.-__._.---._.___.__..
rX4 Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
---------------------- ------ -----�.......•...;, •- ! 1.....................�....__... ---------------
O Description of Soil--------�5..' _ �j------ -u��(� �r•��.C`
�4 +l � rl 7 /7_l 1- 3 t 1. Af.1+ !i +' fla+e J
W(� oa r' ?y �� ,mil / �.r..�` --� � ���a� - f •--------------- - --
•---•------ --------- = ' ----�- --•-. -�s�/. �..' :.�........��.
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 NI of the State Sanitary Code—The undersigne&further agrees not to place the system in
operation until a Certificate of Compliance has been issued by th�e.board of health.
- ----------
----�=5--`--
_�Date
Application Approved BY ---•-- - -- - -- -- = - -�s r
Date
Application Disapproved for the following reasons:.---------------------------------------------------------------------------------------------------- ----------
-•..................••---------•--------------------------------------•-•--•----------•-
e
PermitNo......................................................... Issued---------------------- ....................DatDat.......
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...............!.... s`.�'?�? OF................. ..
............... � *l '
..............................
r C.rrtifirate of 10.11,11MVIinnre
THIS IS TO CERTIFY,IFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Installen
., � ' ,S 7 Oar - o�
f ! '= C ,-r / _---•---......-- ------ -----------
at �� '•-
has been installed in accordance with the probsions of : r'g6l-.e XI of Tllae State Sanitary Code as described in the
application for Disposal Works Construction Permit Noi=-''____.- -_-_ dated ` =
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector--------- ••-•--•-•--•--....._....------•-----------------------••-----•----•..-----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
1 .....of......... ---..._.....•--....--------- Ar
No.-......
' FEE........................
DisvolialAark%g Tunitrur#ion Permit
f f-
Permission isG reby granted---------- --------`-,"�-•!f�'......(---------------------------------------------------------
to Construct;(/) or Repay'/( ) an Individual Sew ge Disposal System' / f
at No....=% .....__ /�,/' /�1?.(�?! �/ ...... L!_!'lrt%. �.�Lrr t �•--'��-------------------------
Street'
as shown on the application for Disposal Works Construction Permtt A
-� P
i �
PP P �No.. a"ted.. `-? t� .
-----•-•---------
f Board ofr Health
i
DATE................................................................................ ,
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
BY DAT SUBJECT SHEET NO OF
HKD BY DATE JOB NO. y. Y
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