HomeMy WebLinkAbout0107 MELBOURNE ROAD - Health (2) lb'1 (nelba��ne lzocd
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAL`f H
.........._.OF..........Xd-1-0 ...........
Appliratinn for Digpaaal Workfi Tonstrudion Vrrntit
\ Application is hereby made for a Permit to Construct (") or Repair ( ) an Individual Sewage Disposal
Syst at
"V-._'___��...... ....... .. .. .... ....i.... P-_..�.`._...--- ...........'.....--....-..
/� l '!�t No. .
Locati -Add ss
.......................... �P... .G�, ,� .. �d...... d.. ..........
... ` . .. Ow 4 ....................... .................. Address ._ ......................
.fit .c
lnstaller Address
QU Type of Building Size Lot............................Sq. feet
Dwelling . No. of Bedrooms...............7...................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures ...... .........•---•------------------------------
--------------------------------.---.---------------------------------.._..-----------------------
W Design Flow.......................1L" ........gallons per person per day. Total daily flow.....................__gallons.
04 W Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
Disposal Trench— o..................... Width............ .,r tal Length___.......... Total leaching area.--..- __.--__.....sq. ft.
x
Seepage Pit No.................... Diameter_ , �' ep{h below inlet....... Total leaching area.j.V'-sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation-Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................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........................
9 .........
0 Description of Soil------------ �a-$-�- - - -- -
V .............-••-••----•---••••-•--•••--•-----•-•-•••••-•••---•--••--••----•••-•-••............•••--••--•-•..............•-••-•---••---•••••-••-------•••••••---••••---••-•-•--•----...._...-••-••.....
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 YI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issjaed by the board of health.
Date
Application Approved By....: .. .i.... _ -- - - �*:................. �_�.`•�-..
to
Application Disapproved for the following reasons: •--••••-•--.......-•--•----•-•-•--••----••---..._...••-•--••-•-•---•------•----
-----------------------••--•-••-••-•••-•-•-------------••--•......_...._..••-••-----......••---------•-•----•--•------•.•..-•----•-•-•-.........-•-•--------••--•-•--• .................................
Date
PermitNo......................................................... Issued...---------------------..............----..............
Date
. . ............................... -------------
No. ----•----- -.._ FEir........ ................
THE COMi%4ONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
J�
Applirativit frr Bi ipwi tl Worko Toustrurtiou ".e mit
Application is hereby made for a Per
mit to Construct ( or epair ( ) an Individual Sewage Disposal
cyst at
{�...ri.... 4..:�-...... ......�d .Faa►P3.t. r��_ fie4,rc.�;v u....... (/.:a. rt'.'. f_F.✓'. 'frs�_ .: _.S!f:...
Locatigf Adds of No. ��
.............. __ - ="�•-. r �e's. ad.----- .._ QF..€ ---------
1 AOtivn r Address
rL,._.. ..�.7 ..................3_.................._
Installer
� Address
UType of Building Size Lot............................Sq. feet
Dwelling ..........Expansion Attic ( ) Garbage Grinder ( )
-''No. of Bedrooms..................
Other—Type of Building .._..... No. of persons............................ Showers
a g--------------------•-----------------------• ( ) — Cafeteria ( )
dOther fixtures •-' •-----------------------------------------'---•--' .-.... -- --•----••••-.......
W Design Flow.................... . `_.__.._.gallons per person per day. Total daily flow.__.___._. .:a., ,o; ---------gallons.
N Septic .yank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No ................... Width _ �.,T, al Length.................... Total leaching area .sq. ft.
j Seepage Pit No.... ... ......... Diameter./_,_ kept below inlet.........40.i....... Total leaching area. r....."`: .sq. tt.
Z 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.___-_---_-----__---__.
f=, Test Pit No. 2................minutes per inch Depth of Test Pit.------------------- Depth to ground water........................
ODescription of Soil.............. ` `. ......-................................................................. --------------- ..................................
U ..........................................--••-•-•-•--•--••-•--•-•-••-------•--•---'--•-•---•--.....'••--•---------------------------•-•'••-----------'--'-••......-----
W
VNature 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 iss ed by the board of health.
Signed. .:.. �-
----- ---------- -
`-✓ Date
Application Approved By. .. = t - - '" ':,;-! -�. ------ e.
..
�' -
Application Disapproved for the following rca.sons---------------------•-..------ 1-.-.-----------....--..-----•---.------------.-•
•-------•--•-----•---•--•...............•'-------•...._...•••---.....--•......--•••-'--•-•--•-'----'---•-------• ----•-----.....---•------------•---•--•---•--...--•-•-•----------......................
Date
PermitNo........................................................ Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD Of HEALTH �...
Tntifiratr of W11111mplitturr
T,Q IS TO CZRTIFF That t11,4'Indi i4tial 5e.wage Disposal System constructed ( ) or Repaired ( )
F'i � t Y 3
by... ''-�`�r��.f=�, t�-x�.�,.�, 0 �--�''"«-�=�- � 's---�:--�:�........... - ---.. . ...r .----- -•• ;. --•-•-•...........
/�
has' ze_n installed in accordance with the provisions of Article XI of The Stat Sanital'"v Code as d scribed in the
application for Disposal 'Works Construction Permit No.............. �_:__° '`....... dated 1� 3 ��,�` .. ..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE '..a:. ------ 0............................ Inspectore. r_... 2 d- :........._........
THE COMMONWEALTH OF MASSACHUSETTS
1 BOARD OF HEALTH,e
,t, "t,�r: ,.y......... 0F......
�e... _. '-... FEE---. ..... .........
No.....
�,r �r v
Permission s hereby granted__..__ £_., ". ',z`` �__.__.. ,�.:.? ss : c..... 4�.1
.....
to Constr r Re aar ( ), Incvszlal Sewage D sposP?ystem j
. t� a J)+
at NO... ,ftb.._.. - ..: .......... .F� .s#wesXs_ �:Es.+ew:{j - ...__..": .:..... d . ,.c.S�.., 1
Street / 7
as shown on the application for Disposal Works ConstructiowrTZirnrit
r -----
b e� )/Health.x` i .fy... d�
Board of
DATE--.... .. .... =- .....:.. .....:........ ........
FORM 1255 HOBBS & WARREN, INC., PU.el_ISHER$.