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Home My WebLink About0170 MELBOURNE ROAD - Health 1�o m-n�ne mad No.... - ------- lS�� Fnic THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH \✓� ...-._-..._O F....... ..................... 1 , pphratinn for Diipnsal Worko (Innitrnrti,an Punfit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System : / ) ation- ddress AdTessb ot N . caner ...... 1�+�.:ki........ �L.et . ..... ................. ...........................................................:................................... Installer Address vType of BuilditlV Size Lot............................Sq. feet Dwelling L No. of Bedrooms................................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—Type of Building No. of persons-------------............... Showers — Cafeteria Q' Other fixtures .............................. .. --------- W Design Flow..................... ..gallons per person per day. Total daily flow......_.__.. .:_..:._..._____._..__--g-a- llons. WSeptic "Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.._.. ----------- Total leaching area._; ....sq. ft. Diamete/�.�.... Depth below inlet-�............ Total leaching area-. _sq. ft. Seepage Pit No---------/-------- 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---.__--.----_____.--_.- Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-_-_-------____......... a -•--•••-••-•--------------------••-•---••••-•-•-•---••--••---•••-•--••...---••--•--••-•-••-•••............................................................... 0 Description of Soil........................................................................................................................................................................ x U -•-••-•---•-----••------••-----•-------••-•---•••--••--••-•.....---••-•---•••••-•-•---••••••••••----•---••-••-•--•-•--•--.....--•-•---•--............................................................... r4 r ---------------------------------------------------------------------------------------•-•-----•--••---------------•------------------------------------------------------------------------------_----- 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. Signed " ` ` — / Date Application Approved By......... •--.... .... •-• -• • .......... ------- Date Application Disapproved for the following reasons:....................... --.---•--------.-------.-.---.---.---.-.•---_......._.......--------....... ....-----•-----------•---------------•-•-----•---•--••----•---•-••-•-•---...............-----•----------------•-•-•--------...-•------•-----....--•-----------•-------•-----•--•---•---------•-••-••-•-- / Date PermitNo.•...6� =---�-----------------------•---. Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD PF HEALTH :- ..----- OF........� °'.. . Application is hereby made for a Permit,to Construct ( ) or Repair ( ) an Individual Sewage Disposal Y S stWai � r/f� �. ''�I 't? cation-Address pr Lot N .. .i 911 Mkt f.. rC. y�4`�................. ..................... ....... .wner °Address cy........ .................................................................................................. 1-4 P Installer Address UType of Buildingf .» Size Lot............................Sq. feet F—I Dwelling No. of Bedrooms...................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons------...................... Showers ( ) — Cafeteria ( ) Other fixtures ...................................................... W Design Flow...................... ! ...........gallons per person per day. Total daily flow_---_,-.-_ - ...............gallons. P� Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ xDisposal Trench—No..................... Width.................... Total Length...... -:__.._._._. Total leaching area ft. Seepage Pit No----------/-------- Diameter/�.' Depth below inlet. .............. Total leaching area. .........:�".sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date....................................... Test Pit No. 1................nunutes per inch Depth of Test Pit.................... Depth to ground water-__-_---.-_----__---_. (14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---_-_-----___-_-_--_--. Ra ---------------------------------------- •-------------------------------- --------------- -... .•••---- ------------------------------------------------- •------- 0 Description of Soil........................................................................................................................................................................ r� --------------------------•----..--•--- V Nature of Repairs or Alterations—Answer when applicable........................................................:....................................... ----------------------------•-••----•.....-•----•••••---•-••-••--•-- Agreement: The undersigned agrees to install the a-foredescribed 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 js�ued by the board of health Signed- r Date Application Approved BY ,. . --- . ......` °' --------- Application Disapproved far the following reasons:...-•----------•-------------------- -----------------•---•--.........------•---••---•-••.....�......--.--........ ------•-----•--•-•--•--...••------•-•--- (.-.............•--•----•-•--••-•-----•-•--•--•--••----•----.....-•----------............_.. ....---•---------------•-•--••-----•----•---•-•----............ Date PermitNo. ;? .............................. Issued.---------._.....-------------------••-•-•---........ Date THE COMMONWEALTH OF. MASSACHUSETTS BOARD OF HEALTH :........ OF......... .....:........................................... Tprtifirafe of Tilutphattir TI-I IS TO C-ERTIFY,1I.T at the In ividual S`eria ='Disposal System constructed ( y<or Repaired ( ) by ��. ----- }! ' r- - � � } �r� �/ 4y F( d�..F�- ..�r' o r l at.-•. . .- •. .. ` Ol r'wr - �p----- --- - ---- ••--- --- -- -------- -- ----- has been installed in accordance with the provisions of Artacl�G I of The State Sanitary C/,Ole a'j c,ks€p1)ed in-11ie 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........- =-- --- ... Inspector.......P THE COMMONWEALTH OF MASSACHUSETTS BOARDr /OF HEALTH r� r No......................... FEE. .................. Permission is hereby granted........... .................................................... t.. to Construct j-)ror/}repair (5 ) ail fiidivi ual Sewage Disposal System A�, ! ! -�--- at No street• as shown on the application for Disposal Works Construction Permit No.,._ ............. Dated N Board of Hcalth DATE---------- _...................................... FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS -