HomeMy WebLinkAbout0164 MEGAN ROAD - Health (2) 1�`V n�� 2oa�
{� y _ �1 � z�o .-
No... .- ..` �. 1/I ^�"d� FIas..e-c...L� .
THE COMMONWEALTH OF MASSACHUSETTS
a....................
7��
®ARD HEALTH�1 -------.OF..... ....- ... .
Y .
V
,�.�:Plutttilln for Eltsposa1 Worko (nomiUurtiott ranfit
Application is her y made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
....;IrO
t;oor
.._.'....�ress --------------- ---Lot-No_
Oer ................•------....-----.Address
a
� Installer Address �
U Type of Building Size Lot__/./'._?�` //�2-.Sq. feet
Dwelling—No. of Bedrooms.____....�7______________________________Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fix e
w Design Flow...................0_.._...._......__gallons per person per day. Total daily flow___-___----���---_•--.______.___gallons.
WSeptic "Tank—Liquid capac ' allons Length................ Width---------------- Diameter---------------- Depth_._.________...
Disposal Trench—No........____ g q.
x tdth_.__._ __.. To 1 Len -.. Total leaching area____________________s ft.
Seepage Pit No. �� pt Total leeching area sq. ft.
er -
Z Other Distribution box ( ) Dosing tank ( )
aPercolation 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 ------------ - -----
-- -- ----
---------------- -- -------- �. -
w
UNature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------------------_.
----------------------------•------------------•----•--•-------•------•-----------------------------•--------------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal Syste in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further a ees n to lace the syste��1 i�
operation until a Certificate of Compliance has been ' ue &tard.of health. ��J
Sid -- •--- ------
Date
Application Approved B
Date
Application Disapproved for the following reasons--------------•-------- ---------------------------------------------------------•--------------------
---------------------•--.....................................--•--•-•---------•-------••---------•--•-----------•----------...------•------•---_.....----------------------------••-•••-•------------.
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
B®A R® F HEALTH
_7��
oF..... .. 11.. ..................................
Apli iration for Uigpooal Worko Tonotrnrtion fierutit
Application is he y made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at: /
... -----• -• -•-•- ----------- ........--- `'y'f. ..... ............. .........................................................
ation-Address 1 or Lot No.
•------------------------ ----.........................---:... -.. _ .._[...w/../....................................................-----......---1.........................
O er -� --�` ...............•----•---------------Address
W
a -----------------------------Inst Installer' ...
----- - -----------------------------
Installer Address
Q Type of Building Size Lot../�/22 S feet
U Dwelling—No. of Bedrooms..______- y q
_Expansion Attic ( ) Garbage Grinder ( )
`4 Other—T e of Building No. of persons____________________________ Showers — Cafeteria
Q' Other fixture
W Design Flow______________J T .................gallons per person per day. Total daily flow.._..__....�0-GJ_____-________-----gallons.
WSeptic Tank—Liquid capacit,�/� l allons Length............... Width---------------- Diameter................ Depth-_-.__.____---
xDisposal Trench—No. .................... Width....... .---------- To 1 Len __-- ------------- Total leaching are......................sq. ft.
Seepage Pit No. � er. ) .pt .................. 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 Test Pit.................... Depth to ground water_____-_______________---
li, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.--_--________-_____.._.
W -•-•-------•------•.....................•--•-•-•--•--•-••-••------------••-••-•---------......--•••-........................................................
0 Description of Soil....../-------------------- --•----------••--•-•--•- ....................... --------------------------------------------------------------------------
U -------------------------------------------------------------------------
W
VNature of Repairs or Alterations—Answer when applicable.______________________________________________________________________________________________-
--•----•--------------••---•--••-•--•---•-----------------------------•-••-•----•-•-------.------•-----------•-----•-----•------•---------------------------•-------•----------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal Syste 'n accordance with
the provisions of Article XI of the State Sanitary Code— The under igned further a rees n tosplace the system in
operation until a Certificate of Compliance has been ' ue by and of health.
Signed------- -----• �V
�- / /
/ f Date
Application Approved By............ J'
' Date
Application Disapproved for the f ollowing reasons:------_-_-•-------- ----•-------------------------------•----------•------------------•-----•-----------
------------------
Date
PermitNo......................................................... Issued........................................................
Date
T COMMONWEALTH OF MASSACHUSETTS
BOAR F HEALT .
.. ...... ............O F. . . .......... ........... .....................................................
Tertif irate of Tomphanre
THIS S - O CERTIF , That the dividual ewage Disposal System constructed ( or Repaired ( )
by.......... . -- ••--
a ----------�-1---••-------- -------------------
Installer
has been installed in accordance with the p visions of Articl XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated-------------------------------------_..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............// ...P/w--7---?",------------------•--------•--•-------- Inspector----- /a�-d�--�--_- .
HE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.... ..........OF .............. ....... /....' --��
No............ •. FEE-_ 2,__ -•--•------
--
Permission is h by granted . -•--•-...._...--•........ ...........• -- ---•••---------------•• --••c ........................
to Construct r�Jjiepair ( ) an Individual Sewage isposal tem
at No. -- -f----
Street
as shown on the application for Disposal"Works Construction Permit No--------------------- Dated-----------------------------------.......
OF
................................... •--•-----------•-•••--
1 . .................•....................... oard of Health
DATE......... t
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS