HomeMy WebLinkAbout0124 MELBOURNE ROAD - Health l�� rn
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LOCQTION SENN&C,E PERMIT V-JO.
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IN T LLER•5 W&� AE ADDRESS
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BUILDERS tJ &mF- P, ADDRESS
DL1TE PERKA T ISSUED
DATE COMPLI ht ACE ISSUED; �- '
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
.. h---------- ---OF..... ......................r1 . cie. - .......--
Appliratinu fur Uiipuiittl Wore Towitrurtiou Urrmit
Application is hereby made for a Permit to Construct (t_-�—or Repair ( ) an Individual Sewage Disposal
System at:
L
----... -•-- -� -•- ------ 9
-•-•-�L,occation/-Address . /y r Lot No.
S_ A-___'_" v eS'_. l_ .l __---------•----------------- 5.��.crv.a svavnn. .....-•----•--•-------•--------•----...---•----
Owner Address
a JZ
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nstaller Address
Type of Building Size Lot_/0`/_-d':*"v_____Sq. feet
Dwelling—No. of Bedrooms..._..______________________________Expansion Attic ( ) Garbage Grinder ( )
04 Other—Type of Building ____________________________ No. of persons----------------------------- Showers ( ) — Cafeteria ( )
04 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.
31
Seepage Pit No!.......?_...Y.. Diameter.__. .._ Depth below inlet___ _________ ___ Total 1 aching area..................sq. ft.
z Other Distribution box ( ) Dosing tank �j��'�
'-' Percolation Test Results Performed by ___
.6F 4____ _________________ Date---------------------------------------
a
a Test Pit No. 1----------------minutes per inch Depth of "Pest Pit--------_-------- Depth to ground water.-.-_--..-_-_._.--._....
ri Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water----------------:-------
--------•--•-- --------- -- -------- -
Descript' Jt pf Soil-.--=- al d -+- / .. ...4tv, ------- -
-----9+ ... rt
x - 1 /
----------
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U Nature of Repairs or Alterations—Answer when applicable---------------------------------------------------------------------------------
--------
Agreement: -
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accor nce with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place e system in
operation until a Certificate of Compliance has be issued by the board of healX��_
Si ne l/s ------
Application 5 ••--•---.-. _
(y --
= Date
Application Approved By--- — �f! `wgy� � ---- .
to
Application Disapproved for the following reasons:.... .._....--'-----------------••-•--'-•
---••-•-•--••-•-•-•----•-•-•-•-•----•-----•--•------------------------------•--------•----•--•-------•-------•----...-----_..------.._..--•-•-•---•---- -•-•-----------------------•-;�---------
Permit No......................................................... Issued...
•- ......... ----------------- --------
Date -
No...................---•••. FEs.............................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® F HEALTH
.... .0F.......... ...... .. ....................................................
Appliration -for Di,4plofial Workii ( owitrurti n 13rrmit
Application is hereby made for a Permit to Construct (" ) or Repair ( ) an Individual Sewage Disposal
Syst at:
F"q
-- ------------ -- ----------
Location-Address _ or Lot o.
-------------------------------------------------------------
caner a ------Address� �� --------------- ---------
Installer Address
Type of Building Size Lot----------------------------Sq. feet
U Dwelling—No. of Bedrooms------- ............................Expansion Attic ( ) Garbage Grinder ( )
p`4-I . Other—Type of Building ___________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
G4 Other fixtures --------------- -------------
WDesign Flow.........;,I.D-------------___''_``-_'----_gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank Liquid capacityli ;_llons Length---------------- Width---------------- Diameter---------------- Depth................
x Disposal Trench—No_ ____________________ Width-------------- of L h/_ ____ _. _ Total leaching area--------------------sq. ft.
Seepage Pit No.._....r..________ Diameter.. _..._ pth ow tnlet__'�f^.__,__ Total le c] ing are a._.._..___.._____sq. ft.
w
z Other Distribution box ( ) Dosing tank 4 `) ✓ ' "� --
~" Y
Percolation Test Results Performed b e ._p. ........:........................ Date---------------------------------------
a
a Test Pit No. 1................minutes per inch Depth of Test Pi .................. Depth to ground water...---.---_--_-----.-.
5(� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--._---__-__-_----_.-.
. ----• --.... C---------------------------
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D r �-.. !� , `Description o o _--; ------ -------- ---� . _..__ ,-----
-- --------- -------- --- --- -------� - � � _ .
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Ni
x ------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable--------------------------------------------------------------------------- ----Fc'A ....
!t ..-.
--------
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accor ce 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.
Signe = ............................................................ ................................
D to
Application Approved By ------- /"*
PP PP Y---- DateAPPlication Disapproved for th.e following reasons:----••-------------•--•-------•-------- -•---------------•-•------------------.......Da.t.e..............
---•••----•-•--•-•------•----------------•--•---•--•-----•••------------••••-----•-------------•-•-...----•-•-----•---•--•-• .................................................. .......................
Date
PermitNo......................................................... Issued.........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
C.rrtifirate of TlImpiianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by.............................................................----••-•-•----•------------•-- ..................................................... _----------
Installer
at....................................................................................................... .----------------------------------------------4 .
has been installed in accordance with the provisions of A ti' XI of T e State Sanitary Co das described in the
application for Disposal Works Construction Permit No.-.��__...._..��7........._... dated......�!,471.�.....,..)----------------
THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.....................................................--•---•-•--•----------_..... Inspector...................................................................................
t
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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No......................... FEE..
13inpatittl Norkii Tontitrurtiott ramit
Permission is hereby granted-----------------------------------------------------------------------------------------------------•---•-•-•-••---._...._........----------
to Constru p:# ) or Rep�ir��( ) an Individual S wag Disposal Sy�em
atNo. , _ '� G ----------------------------------------------
t t 't)
as shown on the application for Disposal Works Construction Perfiit o.___ �'�__'__`:..... Da .......... ...
^ ----•- t r ---f - C
Board of Health
DATE_-•--•-•---•-------------------------- ------------------------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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