HomeMy WebLinkAbout0168 MELBOURNE ROAD - Health (2) 11�8 dY��lbcurn-e, (ZOgd
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No.._ Fizz.... ._.........._
THE COMMONWEALTH OF MASSACHUSETTS
ROAR® ®X HEALTH
[ ......
Appliratinn for Ro ngnl Workii Tonstrurtion Urrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System
---`----- - -• --•- a .Ob.-........ . ..... •---- ......................
Locati .-Address Lot No..�%' s
..... . . ....... ..�1. .................................. ...................... ..... ... .--.:.........._......................---
Owner Address
.. .. .... Installer ...e ............. ............................................Address..........................�,.__.
Q Type of Buildi Size Lot_ . �.._._Sq. feet
Dwelling No. of Bedrooms.................................Expansion Attic ( ) Gage Grinder ( )
'4 Other—Type of Building No. of persons____________________________ Showers — Cafeteria
Q' Other fixtures .•._...
Q •--•- --
W Design Flow i.� -_ lions per person per day. Total daily flow gallons.
WSeptic Tank�Liquid capacityl _. allons Length................ Width---------------- Diameter---------------- Depth................
x Disposal Trench—N ._ ________._.. Widt .___....__ Total Length___...___.__ Total leaching area ______ ..sq. ft.
Seepage Pit No: __.__.___ Diameter__ __._ epth below inlet..... Total leaching area.:_ Q 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__.___________________..
(i Test Pit No. 2................minutes er inch Depth of Test Pit.................... Depth to ground water---------------_........
04 •-•-•••--••-•••-- -- •-•------•--••--•--- ------••-----•-•--.........................................................
Description of Soil____________________ ...... ._
x
W
UNature 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 b the bo •d of health.
Date
Application Approved BY 1 •t._� '72
Dat
Application Disapproved for the following reasons_____________________________________________________ ..........................................................
-----------------------------------------------------------
_-__-----------------
•---•----•-•-------------------•-------•------•--_--•-- --------------------•---•-•---•------------•-•---•---------....
Date
PermitNo.. ...........f................................... Issued........................................................
Date
FRic J ................
THE COMI'AONWEALTH OF MASSACHUSETTS
BOARD HEALTH
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System r. f
Lo atio address Lot No.
" ................................. ....................
:_._..._ .e!'
Owne Address
............ ........................................... .............---------------•----•--------.-- ----
€. Installer Address
Q Type of Buildin /` Size Lot �/.x°: .....Sq. feet
Dwelling-No. of Bedrooms................... ..... ..............Expansion Attic ( ) Garbage Grinder
a`-4 Other—Type of Building ..._.___. No. of persons....................:....... Showers —
g ------------------- ------------ --'- ( ) Cafeteria ( )
Q Other fixtures ----------------------------------------------------
W Design Flow... --.--.__ �......__ allons per person per day. Total daily flow...........y j--- '-y _____gallons.
,!} T.>
� Septic Tank Liquid capacity.,,41 allons Length................ Width................ Diameter................ Depth...............
xDisposal Trench—INN. ..............:...... -Width............ Total Length_._.........,.e.... Total leaching area-_---_._..._......sq. ft.
See a e Pit No. ._ iameter_. ," Total leaching area.... . ,. -cq 'ft.
p gf,l--- .... Depth below inlet_...... .:i,._......
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---.---_-__.__-__-_--__
r-T., Test Pit No. 2................minute�J..)er inch Depth of {Test Pit.................... Depth to ground water------------------------
O Description of Soil..................:- - _ _. : - ..
W
UNature 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.
Signed . ",
�1 f / v z fi r+ / . .................. ..
-• �/ C �/ r �,,�1 t Date
j
Application Approved BY '"' ------- �� /�` .. .. ... '. '..
L f• t..
Date;'
Application Disapproved for the following reasons:...........................:......................... ................. ......
........--•------------------------•-------.....-----------------------------......-•••--•••--------••------•--------------------------------------.......--------------------------=-------------•----.
Date
Permit No.•••• Issued....
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
1
Tertifirate of Tnntpltanre
T ff S1IS TO CERTIFY, That Individu/Sewage Dis�ssal System constructed ( or Repaired ( )
s / I,st.u�tl
at. ,
;_✓_ fi _rl�l'
has een installed in accordance with the provisions of Article X ofe State Samtar, C e yes do rit 'd in the
application for Disposal Works Construction Permit No............... ...0---.•--___________- dated._ ,_L_ ...x._._�--__ �.—n-'
I P P t' -�i-
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT EL CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........... =a--/.--•-• Inspector t .........
.... .. �Q7s .................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD �OF HEALTH
w it eve,�
No...1 .........
43ifipmial ark-s OWmitr ion 'permit
Permission is hereby granted .....j'... ` `_.(�`E ..'.f�_ �` ` `' Af
-••.... __. ... •--•-•-•.....•-•-••........--•---•..................
to Construct or Repair ( {y� an Individual Sewage Disposal System`
as shown on the application for Disposal Works Construction Permit Street
NoZ/<,'.�...... Dated:- ,P......sr?._:.':.r '`......
''
Board of aFlealth
DATE. ........................
FORM 1255 HOBBS & WARREN, {NC., PUIRL[SHEPS .