HomeMy WebLinkAbout0092 MEGAN ROAD - Health (3) E6A N READ
=2 �a- a 9z4 Nya nn is
Fizim
THE COMMONWEALTH OF MASSACHUSETTS
EOARD F I-HEAL7
_... ...........OF... ... ---........... -- ......-.........
Apli iration -for UWVoiial Worko (n aw4rurtion Pprutit
A lication her y made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal
System at: .. -----• -: ._....._..__..__
at' n-Address or Lot No:
c ...r ___"a....
_._..__--•- ------- ......... . ............... ...... ---------•----- ...._.......................... .._..._..._..._--._._....._........_..._.
Owner Address
W
Installer Address e�
Q Type of Building Size Lot_ ® ..�l.1.Sq. feet
U Dwelling—No. of Bedrooms__._•.._.. Expansion Attic ( ) Garbage Grinder ( )
U -•--_------•--------•-'a -Other—Type Type of Building ............................ No. of persons._._.........__......_...... Showers ( ) Cafeteria ( )
a' Otlier fixtures ---------------- ------------
W Design Flow. ... .................................... allons per person per day. Total daily flow---------------------------------------.----gallons.
WSeptic Tank—Liquid capacit _ _.____:_ -lions Length---------------- Width................ Diameter...........----- Depth.__._-_-_.-----
x Disposal Trench—;- idtli.................... Total Length_-_-_____-__._.__--. Total leaching area....................sq. ft.
Seepage Pit No--------------------- ameter.................... Depth below inlet.................... Total leaching area-------.----------sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-------------------------------------------------------------------------- Date-_----------------------------••-------
,� Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water-------_--_-.-.-_--___.
Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water--_----_.----__-_-.__.
•--•--..--•--------------------------------------------------•-----•----.------ ----------•------------------------•----•-..-----•-•----------------------
0 Description of Soil---------- - ....................... ............... . ............ -- ---------------------•--•--•--•---------------------------------•--•--------
V ------------------•--------- .......................... ............................. -- ---------------- -------------_---------------------------_-------•----------------------------------
W
UNature 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 Nl of the State Sanitary Code—The undersigned Wier agrees not to place the system in
operation until a Certificate of Compliance has bee issue he board of lth.
Signed
,J f- -- D to s c
Application Approved BY------- ----.�-'--� - ------- - r'�G---�'-� =- -----•---•--- -- -- �
Dat
Application Disapproved or the following reasons------------------------------�.. ........----•-•--•----------------....._.__ .... --•--
PP PP f f 9
--------------------------------------------------------------------------------------------------------------------------------------------------------- ' --------
Da
PermitNo......................................................... Issued.....
Date
yam. u�..���.. ............................-
N '.o. .!
..�__._.. Fs .. .*.. ................
THE COMMONWEALTH OF MASSACHUSETTS
JBOARD F HEAL -
OF.. .. .... .... .`..
Apphration -for Ditip ial orkii T_ tw4rorthnt Vrrntit
Application ' her y made for a Permit to. Construc - ) •or Repair ( ) an Individual Sewage Disposal
System at - _ ,,�
+e, ,. r
a' n-A d ess . or Lot No.
.............{ie!��__. .. .. --"--------- --- - ......... -".............. ."---"---"------ •"--"----•------"---"""---"-----"-"-----"---•"--------
Owner Address
Installer Address
d Type of Building Size Lot .. .5q. feet
U Dwelling—No. of Bedrooms__._. _._..Expansion Attic ( ) Garbage Grinder ( )
—p_I Other—Type of Building ............................ No. of persons............................ Showers ( ) Cafeteria ( )
a' Otl fixtur
Design Flow ___________________________________ allons per person per day. Total daily flow._.._._.._.__..__:.....__ =______........gallons.
9 Septic Tank—Liquid capac ------ Ilons .Length________________ Width.._._.. ........ Diameter-----...._.4--- Depth--.-- ,---_-_
Disposal Trench / idth Total Length- - Total leaching area sq. ft.
Seepage Pit No..................... >ameter-------------------- Depth below inlet-------------------- Total leaching area------------------sq. ft.
Z Other Distribution box ( ) Dosing,tank ( )
aPercolation Test Results Performed by-------------------------------=-=----------------------------------------------- Date........................................
W Test Pit No. 1..............__minutes per inch Depth of,Test Pit-------------------- Depth to ground water.-.-_---_-.- _.------
44 � Test Pit No. 2................minutes per inch Depth of Test Pit--------............. Depth,to ground water--.------_--_:.------_
O Description of Soil.______
U ______________•----._._.
W
x . .----------
I _._----
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 her agrees not to place the system in
operation until a Certificate of Compliance has bee issue the board o lth. `
Si ne ---- D g
Application Approved By...... - ---- � `
Da
tiApplication Disapproved for the following reasons:--------------:........:......_:_..__._._..__._..........._
a. -
: "-•""-".............""--.._.....--•-.....•••-.---""-"•-------------------""""•-"""""•"--"------•---•-"---.__---______"---••---------"--___---------------___-____----'----------------___---------------
Date
PermitNo.......................................................... ' Issued...................... .................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOAR/PopqF HEAL...........O F...: . ... .. ..
�rxtifir��le >�rf f�om�rli��crr <or
THIS IS ERTIFY, T the Indiv* 1 SegeDis osal System constructed ( Repaired ( )
Installer '
at
has been installed tn,accordance with the pro isions of Article X f The State Sanitary Cock as escribe in the
application for Disposal Works Construction Permit No:............. '"_._.._._. dated....__ M — ---___
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS UARANTEE THAT THE
SYSTEM LL NCTIO SATISFACTORY.
DATE------ =" 7 ..................... Inspector---------------•------- ------ -- -_ ....T--------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD A
HEAL
+ ............... OF_.. ...................
FEE CAM`"
___--•-- -•..•.....
• �i��o,�ttl� • xk� Cn � ioi� �r�tit •
Permission is, pgranted•.•. .-- tk
to Constr ct or a air an In ual S e Dis S tem
at No. / ( ) --__-•---g-- et
---- - ------------------- � •"'�'
Stre
as shown on the application for Disposal Works Construction. Per o.____,_.,.•_ -. .:: _.,Sr"` ___
-•---- s.
Board of ealth,-
DATE................................................................................
FORM 1255 .Hoess & WARREN. INC.. PUBLISHERS - ,