HomeMy WebLinkAbout0157 MELBOURNE ROAD - Health (2) `� met bbur n-e (�bo
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No...Zlo --.... F$�.. ............ _
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
��-Z,� n,.-.-.. OF....... .... ....� ` -
Applira#ivn for Riiposal Morka Tone rurtion Pun it
Application is hereby made for a Permit to Construct ( V) 0-r Repair ( ) an Individual Sewage Disposal
System at
.. - .� ..., �.......... .
.....� 'r`t`�' .. .... Locat�o •Address ....... or Lot No.............:..... .::........,.
wner Address
K....... :. .... ....... ..................................................................................................
nstaller Address
UType of Buildigg% Size Lot............................Sq. feet
.-� Dwelling K No. of Bedrooms.............. ...__......__....._..Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons............................ Showers ) — Cafeteria (.
da thg----------------------------------------•-••- ( )
Other fixtures . ------------------------------------------------------------------------------------•---•---------
Design Flow......................�.d.....___gallons per person per day. Total daily flow................. .........gallons.
WSeptic Tank Liquid capacity gallons Length................ Width---------------- Diameter---------------- Depth................
Disposal Trench—No .................... Width......... - Total Length----- Total leaching area....................sq. ft.
Seepage Pit No --_-___- Diameter_)Q "._.... Depth below inlet.-s..... 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----_.-_---._------.-__.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
------•--------- ----- -------•-- --
O Description of Soil...................... .
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 beenisjixed by the board of health.
Sign. --.--.............................. ................................
Date
Application Approved By....... ------ . . . ._f 1tL._ 1, D/7.2._/
Application Disapproved for the following reasons-------------•---- ---------` ................
••--•--•--------•-•-•-•-----•-•--••-•---..............
•------•-•---•--•...............•-•-•---.......----•------•-••-•--••-•----••-•--•----.....---•----•••••••--------------•••-••-------------------•------------------••------•-------•--•--...---•--......
Date
PermitNo......................................................... Issued.......................................................
Date
No---.���� Fps . ........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
41i7
OF
y
....OF....... 4. .`................ .........................
A lifiratiatl. flir ispoll tt lgjarkii (foutitrurfivit Vrrufit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal,
Systea�t�ky
tt AL__o``cat,orx-Address VVV/ f3 or Lot Vo
...... -FY._... .9. •: •�..�'E'� +'- ••say. ................
.. ____..-'
b y, y-Y••° ^�..� �¢„v".+ +yK•t •j'•�• ''`�':�S_
f y
,Ownav- Address' '{
a ..:.....Y m -�...... are ...._... ..............r....._.._...-------•----..._........._....__._.
!.ns alley Address
Q Type of Buildi'91- Size Lot............................Sq. feet
Dwelling No. of Bedrooms................J.'W.................... Attic ( ) Garbage Grinder ( )
PL, Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
aI Other fixtures ...........................................................
W Design Flow........................
'�: gallons per person per day. Total daily flow............... �' " ---------
WSeptic Tank I Liquid capacity_ alIons Length................ Width.................Diameter................ Depth..............
x Disposal Trench—No,___________________Width .... ... Total Length..-________ r____ Total leaching area....................sq. ft.
>> Seepage Pit No.__ ___{ -------- Diameter_ 4 . .Depth below inlet. _.._... ...... Total leaching area, ........ ft.
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__________________-____.
G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
...................... .................... ..........................................................................................................
ODescription of Soil . ---------------•------------------------------------------•-----------------------------••-•-•••-•----
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 YI of the State Sanitary Code-The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been)
ed by the board of health.
Signed -- .
Date
Application Approved BY ti '%J � +� '., ---------- ' « - v: - .
Date-
Applica.tion Disapproved for the following reasons:............................... _____-..........................................................................
Date
PermitNo....................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
... ... d'z4 ' .......... OF........
Trrfif irate of Tomplinurr
THI IS O CERTIFY,6Rat tl),e Individual Sewage as osal stem constr ted r or Repaired
i ' w
Y.
pp
h installed in accordance with the pr'o.islons of Article XI of Irhe State Sanitary Code as descr ed m ahe
application for Disposal Works Construction Permit No...... _. ---------- dated __. __ _ _ ..............
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........ ..;Q."' ------------------------------------ Inspector---• �..... fs , ...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 1 HEALTH
F
.` �' t:..........O F........ �.,.__'AA��..�., ..e��a 1................ FEE
No..... _ __. _ ! t EE. e=n...............
• �t��.�,��
Per'missior reby granted_.__ � �
to Construct (' �2epair �� an Individual S age�Disposal Sys em
at No...., ....:... .. .',.''x' - r "�. rrc r it mod' • ..
as shown on the application for Disposal Worts Construction P ` it i�To. Dated_._._- - -�
-7 Q q Board of Hcalth
DATE
FORM 1255 HO.BBS & Wj,PREN.`INC., PU['.!_ISHERS -
� Y �4