HomeMy WebLinkAbout0305 MONOMOY CIRCLE - Health (2) �oS Mc�uybt-C-41-, CeJ
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
............. L 044 .I ....0 F.. . ....... ..nn n� . ..................................
Applira#ion for Disputia1 Works Towitrnrtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair X an Individual Sewage Disposal
System at:
...... .........._ �/.?1,�12?Cd ..... .).ems ........ ... ..... --------------- ._...... ..........
Locat' d es or Lot No.
I�J.Y � ..... �1 -------- � ..... �. --------------------------------------------------
( n •ddress
d�d-- ..... ................•.................................................................................
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
'4 Other—Type T e of Building No. of persons............................ Showers
Pa YP g ------•--------•---•-------- P ( ) — Cafeteria ( )
P4 Other fixtures ...........................................
d • ---•--.-----•-----•----------------------------------•........
---------
------------------------------
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 inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
a Percolation Test Results Performed by.......................................................................... Date................ ---------------
...
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
0 Description of Soil........ 91'a�-/-..............................................................................................................
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 TIT I.;::. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance hasV,,een issued b the board of health. '
Signed_.:.. ._�� :"�4�...: .
Date
ApplicationApproved BY...........�-c---------- - -- --•-------- ----_:..:..................._..------
Date
Application Disapproved for the following reasons----------------------------•--------•--•------------•---------•---------...-------------------•-------..._...._.
---------------------------•---------•--.....---•--•---------............------------........------....--•-------------------------•----•---•----------•----••--•-•-•------------••....................
PermitNo.................--------------------------------------- Issued---4 ...................................------
Date
i3
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF../.:�1,�r7c..
-.... k...................................
Appliration for Disposal Works Tonstrn.r#ion rrmi#
Application is hereby made for a Permit to Construct ( ) or Repair (;h) an Individual Sewage Disposal
System at:
................_... ..._...:....-=-- ................. ••••--•••••-....._..--••-..._.............---••---••••••...._...----••...................--•-•-•--
Locatiox-Address or Lot No.
Owner Address
a L.................f....................... •-•..............••-----._....._...............-•-•••••----...._..........._.............•-•---...
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
a Other—T e of Building No. of persons............................ Showers
QI YP g ---------------------------- P ( ) Cafeteria ( )
QI Other fixtures .-•---•......•. •--•-...-•---•--- .
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 inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by......................................................................... Date........................................
a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
k, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
----------------------------------------------•-••--•------•--.......----------.....----•---...............---•---••----•-•--•-•-••-•----.....----••---.--•--
xDescription of Soil............l-•--=! -......''-= ..:. 1 -------------••-•---••----•-----•----•••--••-••---••.......-•---•••-
V -----------
•--------------------------------------------
••------------------------
...
W
UNature of Repairs or Alterations—Answer when applicable__________________ -:4 l
------------•--•..............•-----•-•------•-•-•--------------•--........--------•-----•••••••----•--••••••••--- •--••-•••-••••••••••......••-••-•---•--•••---••--•---•••--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 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.
r
Signed....................
' = .......................
Date
Application Approved BY - -- -----.•------------------------••--------- ------. 2 �---��----
Date
Application Disapproved for the following reasons:--------•----------------------------------------------------•-----------------•----•-•••-......------...._...•-
..--------•----------•-------•--•--.......---•--------------••---•------..........------...--••--•-------.._....--------•--------------------------....................................................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
f . , , OF....f A
Trrfifiratr of Tompliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( . )
r ,, l f
Y...................
Installer
.:.........:....•--•---.......---^------_. ...........--•-••-- �-- •-----------.�..._.......-•--•--......................_...... - -••---••--•--------•-•-
b .
at.............................................................6 /I.. ` 1 f f_:
--......----•--•--- .- ••--- --- -
has been installed in accordance/with the provisions of F' 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit N 1...... ............... dated___h/-_,,1_2'_d<j.................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
L•
DATE.. /- ...................................................... Inspector......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
;P % . ..................................... - ?.
N �....... `...'..............OF....................._.....:............ FEE.................
Disposal Works. Tonstrudion Prrmit
Permission is hereby granted......:�...t...---__:£_--•------- •'I' i'
to Construct ( ) or Repair ( an Individual Sewage Disposal System
at No........ ..............�= r ' 1/%r '/ ' I , < J,
.•--•---------•.................••--•--.--•••••.........•--••-.
f Street '
as shown on the application for Disposal Works Construction Permit o.......... ... . 1.................................
...........
DATE.....-I-/------------------••----•-------._...................................... Board of Health
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS