HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. ro.W.0........ . ............ OF.......... ..........................................
Appliration for Disposal Murky Tonstrur#flan Frrmit
Application is hereby made for a Permit to Construct ()() or Repair ( ) an Individual Sewage Disposal
System at: g
Lon - sor -- t No.
--.. iT---=....�`--------------------------•--- -3.Y.3..._....,�r .rstt...... ....
ociAd s
In-
..............................
►-� Installer Address
Type of Building l3Size Lot__ 9 0:D_._._...Sq. feet
Dwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (/')
p-, Other —Type of Building ............................ No. of persons____________________________ Showers ( ) — Cafeteria ( )
a Other fixtures ---------- -•---•--------------------------------- . _-
W Design Flow --------- LLD __________________________gallons per person per day. Total daily flow ........... -b. .................... gallons.
WSeptic Tank — Liquid' ca.pacity.i o00 _gallons Length___ . Width_ �__► o __. Diameter________________ Depth__5
x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ------- I............ Diameter ....... I_�.._____. Depth below inlet .......... ...._.. Total leaching area... �-.>___.._sq. ft.
Other Distribution box ()( ) Dosing tank ( )
z Percolation Test Results Performed by-___-____i��__.d'J�-•_tx--______________________ Date ... yl�_51-�__............
a ___
,.a Test Pit No. I .._.___1—.__.minutes per inch Depth of Test Pit___L___-----
��..... Depth to ground water________ ___________
Test Pit No. 2._-4ti'..... minutes per inch Depth of Test Pit --- I_ .F�-------- Depth to ground water ..... 1`}_.__. pAA 7
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O Description of Soil----- ...�?:._._.
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...5�--- .... -------..L-4'.----------------------•--...-------._.....------•-------
UNature of Repairs or Alterations — Answer when applicable ...............................................................................................
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of .ITEC 5 of the State Sanitary Cod e ui ersigned further agrees not p are the system in
operation until a Certificate of Compliance 6n slue a th.
Application Approved B
Application Disapproved for the following reasons: ---•-------------------------------------------------------------------------------••------••--------•••-•••----
--•-•-•----••................•-•-----._...--•-J-----•-----•----•---•••--•----•---•--------•------•----.•--....--------•-••----••-••---••------ .....................................................
Permit No... . &2�w---------------------------- Issued_ D.... /1...._
ate
THE COMMONWEALTH OF MASSACHUSETTS
-- BOARD t10F HEALTH d
...... ................ OF ...... ...-.......................
Tntifiratr of (hunt-pliatta
THIS IS O CERTIFY, That the"�digidual Sewage Disposal System constructed (Vf or Repaired ( )
Ins#,,;
has been installed in accordance with the piW�onsWf TI
application for Disposal Works Construction r it
THE ISSUANCE OF THIS CERTIFICATE /rl.
SYSTEMA WILL FUNCTION SATISFACTORY.
DATE.......... ...... .•=....... a-------------------
..........................................................................................
llu.---- -----...................
TLE 5 of The State Sanitary Code as describ d in the
dated `_/ Y ~"---•-------_...
NOT BE CO ED AS A GUARANTEE THAT THE