HomeMy WebLinkAbout0031 MOON PENNY LANE - Health (3) �i 1 'Yhoavt Rion� lane,6-4
�Gr �Dz�
No-4 P. ( 11 —02J Fly c 2..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEA T .
Appliration -for 43hipliml lVarkii Tonitrnrtion Vrrniit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage D;spos 1 J
System at:
40
� . ---------------------••.._....-----
........... ............4 _e�............X�� oca ddress - -.• or•Lot No.
er Address
..11er Address
dTy of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms------------------------------ -- -Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ___---------•-•--------•--------------- -
Design -Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
W .
Septic`annk—Liquid capacity__..._.....gallons Length---------------- Width_...___------ Diameter...........----- Depth---.------------
xDisposal 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 "Kest Pit.................... Depth to ground water------------------------
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.....
---------------- --------- -------------------------------------------------------------•----•-----............... �-
O Description of Soil --
- ---------------------------------
---------•-------------------- ----------- -------------------------------------------•-----•-•-----------------------------------_---- -----•-
U Nature of Repairs or Alterations—Answer when applicable.-.e ... _. .. ..._..
-•--------------------------------•---------------------------------•'--•--•----------------------------------------------------------•----•-•-----•----------------------- -------------------------
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.
igned_.� _ eGw�c
------•. •.!..l••A-----
Date
--- 1. /' ._..._.
Application Approved By---- ----- ------ -
A Application Disapproved or Me following reasons:................. -------------------------------------------•-------------------
PP PP f f 9
ate
PermitNo......................................................... Issued........... - ....../...................
Da e
No. F��...., ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEA b
_. OF.......... t
Appliration -fur Biipuuttl Works Tonstrurtiuu Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair'-( } an Individual Se age Djspos 1
System at: iK`sLw «•-•`
-
� ''f!r{ ---•-----
ocation dres��s��II�_�,,��,,��,,y. or Lot No.
----IGa�'°' sa
Owner � Address
aA------- a---------- ............."...................•................................................
nstaller Address
UTy of Building Size Lot____________________________Sq. feet
Dwelling—.No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
G' Other fixtures ----------------------------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length................ Width---------------- Diameter-------.-------- Depth......;--------
Disposal Trench—No-____________________ Width-------------------- Total Length._ ................ Total leaching area........-------------'sq. ft_
Seepage Pit No--------------------- Diameter---------:............ Depth below 'inlet___---____._________ Total leaching are€t----------------_'sq. ft.
z Other Distribution box ( ) Dosing tank ( )
a Percolation Test Results Performed by.:----------
........................................................... Date-----------------------=J-.-.--------.
Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water------:_____-.--_.____
fs, Test- Pit No. 2----------------minutes per inch Depth of Test Pit-.____-_-.-.._______ Depth to ground water-----. -_-_--_-____--_
w
ODescription of Soil-------------------------------------------------------------------------------------- --------------------------------------------------- .'
x
V -•-••-----•---- .
----------- ---------- ---- ----- --------------------------------------------------------------------------------
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 issued by the board of health.
igned-- --•- #..!...... ..
Date
Application Approved BY = -",J 3 .
_ - D a e ..
Application Disapproved for t zTe.following reasons:...............................
---•-•-••--------------------------------- ......---- -•...
-----------------------------------------•••----•--•----•-----•----•--••••••------•••••••••-•---•-••---••-•---------•-••-•....--••...----••---••••••-- ---------------- --------------------------
Date
PermitNo-------------•------ ............................. Issued----.........•-•••--•--------•--• -••--•-••-••--••---
Date 1"
t
THE COMMONWEALTH OF MASSACHUS'ETT,S
BOARD O HEALT
OF..... ..... .. .
. .. ... ........:...
CIrr#if at rrf f�rr t :'ttrtr�e
T I IS C Y, That th Individ 1 Sewa is al- stem nstructed ( ) or Repaired
by...... h -- -- ----- - g P .
tall/e1
has been installed in accordance with the provisions of Article of The State S itary Coe as d crib m"the
application for Disposal Works Construction Perini N � ,,r_-.--__ dated------ ... li e ter --- -•--- .•--
THE ISSUANCE'�AF THIS CERTIFICATE SHALL NOT BE CONSTRUED A A G R IVTEE TFIAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......
'�� C Q/ `= Inspector--- --- ------•
.f THE COMMONWEALTH OF MASSACHUSETTS
{` BOARD OF SALT
` No ._ : .. r .........OF...........
'rr._ �*`
� PPP ✓✓✓' ...._.....
�� �i��u�tt ,� �tr�trtiutt rrtt
Permission is hereb rante
to o Cn.stru ) or R` a' ( ndividual Sew e isposal System
at
.. .. ,. •.• ..<. Street' � �as shown on the application for Disposal Works Construction Per o _____ t _
/- 1
� rd of ea ..._...._DATE--••--•• - j -- -'
FORM 1255 HOB S & WARR•EN..,;INC..,PUBLISHERS