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Home My WebLink About0055 MELBOURNE ROAD - Health (2) 55 YY1el boo one (dad �Ccnnis- a�ay7 7 C dr 3 oc� -7 No.-:._ ` / - r Fim.�r................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE TH .. .........'OF......_ :............ ..................... t .. Apti tranan for disposal Works Tonotrurtinn Vv=ft Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal Syst . �-�n1 �1 e0! ` .y..... ...... . ...�1 :1 r !?.�...G. � . ndress r .t.'T .`......... ............... ? Adess . ,� .... ........ ... ................ nstaller Address Q Type of Building/ Size Lot............................Sq. feet U Dwelling-jK No. of Bedrooms_ '.. ..............Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures -------------•-------. ._. Q Design Flow__________________��...-_...__gallons per person per day. Total daily flow............................................gallons. 1:4Septic Tank Liquid capacity/&O allons Length................ Width_..--------_-_-_ Diameter-•---_..__---_-_ Depth................ xDisposal Trench—No.. .................... Width..._....._ ee__e� otal Length........... Total leaching area.....r�__....--..sq. ft. ',,> Seepage Pit No.._.... Diameter_ .4 bepth below inlet........-_ . Total leaching area.... a.. '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-.-.---------_---_---.-. 4, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-.-_--_--___•_-_-------- a - O x Description of Soil................... .. ....u1d 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 undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i sued by the board of health. g ."... Date Application Approved By....-= ........... ... .. -f------ D - ....--•--•................................._..........---•---•-------------_ -- ate Application Disapproved for the following reasons:............ -___-_.-..._._ .................•-------•-••-••-----•-------------------•--•-----.........----------------.....--------•...........------------------•------•-•------------•-•-•---•--- ............................... Date PermitNo......................................................... Issued........................................................ Date r ,�.�... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE44L TH Appliraiiou fur ihrapviial Morkii Tonstrurtion Permit Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal SystemE'a �'7 . �[°� •may S �`" �� i �tion- dress ..._... ... f r� �r I,ot No�� ................ A .........s s� _..�.r.' •••,•'VE•y7"'- _..._ ...... at. �f!= k' -wq.w.. r er / Address . o%F) ,n a ...... y�1' �.41-f..�.�,........ a�,�f1.��s� n� :................... t.-s�ca. -----.----.---------.---•-..-- e nstaller Address UType of B"uilding,,� _ Size Lot............................Sq. feet ., Dwelling-lL No. of Bedrooms.................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ..__.... No. of persons............................ Showers a g ------------•------• P ( ) — Cafeteria ( ) Otherfixtures ---:---- ----------------------------------------------•--------.........-----------•---•••..................•-••••--•-- WDesign Flow..................:. .......... allons per person per day. Total daily flow............................................gallons. WSeptic Tank Liquid capacity+.. .gallons Length................ Width-------_--..._-_ Diameter.......--------- Depth................ x Disposal Trench—No .................... Width..............V otal Length....._._.___-. Total leaching area =-,..........sq. ft. See a e Pit No.._._...__�........ Diameter._ ''� `` r %` ,p g /�`. :�._.`'IDepth below inlet.................... Total leaching area....-:_-.6_.:� ft. Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date......................................... a 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........................ -------------- •--- i-----_---_ -----------------•---------------------------------------------------------------------------------------------------- O Description of Soil....................�,_" ' ----- W --------------- --------------------•---------------------•------•-•••-••-••-------••••••-•--•-••-----------•••----------•-•----•--•--------•----•-••................................................. 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 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.......... �''lg.. ., . �,r�`� === P'•r�',r .r"�s .�.----- ' . 7.`.. Date Application Disapproved for the fallowing reasons:............................................................. •••.......................... -----•........ ....................................................-----•----...-------•..........••--..........••- Datt PermitNo........................................................ Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH s .......J :...........OF........... � :E...a ............ (9rdifira#r of Tompliaurr I TO CERTIFY,;T�at the nds�itlutil wage Disposal System constructed ( 4r Repairedmot.e ( ) ..... _..y. - ... Installer . at. ...............$ j ------------- -- has been installed in accordance with the provisions of Article XI of The State Sanitary Code as descr bed in the application for Disposal Works Construction Permit No...............:5:".7_/------------ dated...... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT RE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �Q DATE.....; = r�•---- '.7'... ---------------------------------- Inspector---••----�--'-. .�.. .. ram. THE COMMONWEALTH OF MASSACHUSETTS BOARDZ HEALT Irlll No. = ---• FEE.. ................ Permissions T hereby granted ?Y,+ =_-- `` err 'tg, •.......... ............. .... to Cons ) �r Repair ( ' an 1 ividual Sewage Dispo S stem t • � � street as shown on the application for Disposal Works Construction Perin ed __� ��: ft ,�� -- !O r DATE.......... _--/., Board of Health7 .. ` FORM 1255 HOBBS & WARREN; INC.. PUBLISHERS - L__. _ :I-