HomeMy WebLinkAbout0124 MEGAN ROAD - Health (2) a4 Vi'ier�*�m �m
�} l� aqa - a8b
No. ----- ........... Fs�............s.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALT a y
_.- . ......OF......... .........................................- ----------
�a pphration -fur Riipuutt1 Workii Cnutuitrurtiuu Vaunt
\ Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
'/� 7
------------------------•. -" -•----------------------- - ------------------ --•-.-.-----------------------------•-------•--•-------•-•--•----------------------------------
or
�!� o tion•Address ._ ......................... Lot No.
ner Address
................ ------•-........
Installer Address �// �7, q
Type of Building Size Lot....._..-_6-i__-_.__.V_.'..�..Sq. feet
Dwelling—No. of Bedrooms--------------------------•---•-__-._---____Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons.-______---__-_-----.-----__ Showers ( ) — Cafeteria ( )
W Other fiat res ---------- -------------------------------------------
W Design Flow------- .-_•-__-____.__-_--•._gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacitallons Length---------------- Width................ Diameter____...._...____ De>th.._....___._._..
x
Disposal Trench—No.; Width-------------------- Total Length-------------------- Total leaching area--- sq. ft.
Seepage Pit No____ _____ _ iameter--._-___---____--_-- 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 "Pest Pit.................... Depth to ground water-.___-_-_.----.------
GZ, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-_.-.-.--_--_-._----___.
a ----•------------ ------------•------------------------------- ...............................-••-----------••-------------------------•---...........
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 NI of the State Sanitary Code—The u ersigned further ees not to place the system in
operation until a Certificate of Compliance has beXssu oard of healthSigne •------• -----••------------------------ -----•- ----_ Date
Application Approved BY .....,
Dat
Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------
Date
PermitNo......................................................... Issued..... ................
Date
Fay. .
THE COMMONWEALTH OF MASSACHUSETTS
BOARb OF.,
HEALT f.
1 .- .-W
`... .....OF.......... ....................................- .......:..................
`Appliration -for Dispo,itt1 Works Tonitrurtion Prrntit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at
6
.......................... ........... . .
tion-Address or Lot No.
wner Address
a -- ----------------------------------------------------------------------------------•----.
Installer Address
Type of Building Size Lot...../___..r._.__...._.__._.Sq. feet
Dwelling—No. of Bedrooms___-._ .......................•------Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ___________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures --•---------------------------- - -
W Design Flow. ... ......................gallons per person per day. Total daily flow-----------_--------------------------------gallons.
WSeptic Tank—Liquid capacit _� allons Length________________ Width_._.__._.__._. Diameter...... D gill.____.__._.._..
x
Disposal Trench—No. _ __ ___ _ '_. Width-------------------- Total Length.................... Total leaching area_..:, X..sq. ft.
Seepage Pit No--------------------- iameter............:......... Depth below inlet......................Total leaching area.___.__..-_.__-._.sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date--------------------.------------.-----
,� Test Pit No. 1----------------minutes per inch Depth of 'Pest Pit.................... Depth to ground water.._.__._._.__._.__.-.-_.
Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water.-.-_._..__-_________._.
R'+ - ------
ODescription of Soil ---------------------------------------------------------------------------------------
x ..
W .._;:.; - --
------------------------ ---------------------------_---- --------------------------------------------------.....-----------------------------------------------------------------------------------
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 ersigned furtheriees not to place the system in
operation until a Certificate of Compliance has bee /issu d y oard of health
Signe -- �-• -�,,/x..`,...--••---•�'L� -------- -- _-fir."--
Date
-----------
Application Approved B .• �.. a,''€ l' '- - "� f .
Application Disapproved for the following reasons:.............................. .....• ------------------------------------..-----------------------••-------
------_---•---•-•------------------•--------------------------•-•---------------------------------
PermitNo......................................................... Issued....r? -= .....................................t , Date
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALT f
OF.........:......:........... ..............:.........................................
Tertifirate of ITNImptittnre
THIS_,,11'T0 CER' Y T _ e Indi 4al Sewage Disposal System constructed or ( )
bY---------- "" ' 'w '� ;. '�"
-------------- - ................................................
" Instal
at-•---•••--- . ------ ------- ----• ................. .'"..^ ......... -'-i�;�---••--•------------
has been installed in accordance with the provisions of Article Xj o fThe State Sanitary Code a deescribed the
cr- *71
application for Disposal Works Construction Permit No--------------- __..__---_-_______- dal
� a"x !.,..r✓.'__ ✓� ' ~*
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 O# HEALIJ�
No----=................... FEE---
Dispotitt1_ orks TIon�t 4trti t der �it
,�•� `P` •.
Permission is hereby granted...... - ---------- ----- ------------
to at Construct (t..�j'"�r Repair ( ) an I dual Sewage Disposystem
Street
as shown on the application for Disposal Works onstruction ; 'er'mit No. _ : ___�_q..... Dated-_
C '1 ///:�
Board of Health
DATE-- " :.-.�..
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
4
fit.