HomeMy WebLinkAbout0147 MELBOURNE ROAD - Health (2) l q M-66urne- P.-Cad
r �r •
No.........�---- 3--- Fimim '1'.................._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9F H EA H
Vr �
Appliration for Rap> nal Marko (9.anatrurtinn Permit
Application is hereby made for a Permit to Coiksct ( ) or Repair ( ) an Individual Sewage Disposal
Syst at: / l
.... :.- ( /I ... .. --
o ation A�sus or Lot No�� A
1
ti... _ .t� .............................. .._ ..... .....
Owner .........................................
.......
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixt res ................t.................•-...._........----•------------------------------------------. .................
W Design Flow......... . -gallons per person per day. Total daily flow._.. . ._.._..gallons.
P� Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—N ..................... Width..........�a�otal Length............ Total leaching area--- sq. ft.
Seepage Pit No .__._._._ Diameter__��' ...... epth 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........................
rXq Test Pit No. 2................minutes per inch Dept of Test Pit..._-_-_________-_.- Depth to ground water........................
R; .................. •. ....................... -----------------------------------------------•-----•-----•----------
O Description of Soil........................ z
x
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 be�i -ueby the board of health.
�/f� • •-
Date
Application Approved By........ • •-•---... •-•--••--•-• 1 -I
at e
Application Disapproved for the following reasons--------------------------------'d_____-----------------.----...-.-•--•---_............._._._.___.._........
------------------------------•---------•---•------.._...........----•-••--•-•-----......---......----------------•••••-•••.......-•-•--•...•---•--•---------•---•••...•••••-------••---••-•---•.••....
Date
PermitNo......................................................... Issued........................................................
Date
ti
THE COMMONWEALTH OF MASSACHUSETTS
Appfir tiVll for Btspvsal Workfi Toniarurtion Permit
Application is hereby made for a Permit to Cons Ct ( ) or Repair.( ) an Individual Sewage Disposal
System at ",
n
. -. --
]o+tion ft d4ess �� � � or Lot No.
.......'�!...F t JG.%4.ew n� .................................. .'..._9 .f 4�-
W Fr Q y s Owner + Address
w
.............................. :...................................-----------•--------
'�lnstaller Address
Type of Building�/ b-- Size Lot............................Sq. feet
Dwelling-kNo. of Bedrooms..................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons............................ Showers — Cafeteria
dOther fixtures --- ........... ........................................................... .
W
Design Flow........ s�% allons per person per day. Total daily flow-_--- _ _____________gallons.
Chi Septic Tank—Liquid capacity------------gallons Length_.............. Width---_............ Diameter...........:.... Depth_____.---_---.-.
Disposal Trench—N ..................... Width.............F otal Length----------
../..... �.Total leaching area----- .....sq. ft.
Seepage Pit No._.../......... Diameter---/_o?- .V...:7" epth below Total leaching area.':IZ�. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by------I ----------•••••----•----------------------------------- Date........................................
'Pest Pit No. 1................minutes per inch Depth of Test Pit.-.--.._-______-_•-- Depth to ground water_-------_--____-__._.-..
(4 Test Pit No. 2................minutes per inch Dept of Test Pit.................... Depth to ground water.--_._---_--__--_____---
� .................. -------------- ------.....----•-----•----------------------------.........................................................
Descriptionof Soil. :.w " --�'f-----------------------------------------------------------------------------------------------------------------
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 issuejd by the board of health.
Signed .fn, �'?"4 '`�.��c� �--...
f �/f�/ �° • ! Date
Application Approved BY---....... ✓L" - s..._.. `�..'... °'1;114 /!-�F'`----•--••--
ate
Application Disapproved for the following reasons:.......•------------•------------ -----------•--------------•-•---------------•--•............................
.........••-••••-••-•••••••-••••..................•-•----•--•-•-••_•--.
Date
PermitNo........................................................ Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
'rrtifiratr of Tompliatta
TFj I IS TO CERTIFrr/That thVIndividual,Sewage Disposal System constructed ( ) or Repaired
Y ( )
b ` ''rr1i.- 2. .yid '✓ r G' ..----
F ---------- -----
at--- . _..t-%'._..� ✓ _. ✓`,% :T_'z2. ' ..03'/ ..-- --------- ------ —-------------------------------------------
has been installed in accordance with the,provisions of Article XI of The St2CEe Sanitary Code a described in the
-----------
application
ISSUANCE IOF THIS Works DCERTIFICATE nstruction nSHALL NOT BE CONSTRUED ASEA GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE. _ ........................................ Inspector...ee!`-..... ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OFj HEALTH f
j .�,- � ......... oF....... �. `p�... -,c.� .......�...'.................
w
No... s:S. FEE..ar :..............
Permission is kreby granted... ......
_ = o" d ;: � -✓ ::f , .wto Construct r Repair, i}ndividwe Iisposal Sys f
at No.......... ....,
`. `^....
s - StreetOle
w+
as shown on the application for Disposal Works Construction Pert NC. �f/�J.a`,�ff Dated .L✓ .. __/ -:' ......
7 .s� `. , .'°�'-. }3aa,•a of FIeaatli
DATE------ --------- -- ----- -----------------.-----.------
FORM 1255 HOBBS & WARREN, !NC., PUBLISHERS