HomeMy WebLinkAboutApp-Permit-ComplianceNo.. ..t ..... .
i Fs�.,lti✓.�.. v..
THE COMMONWEALTH OF MASSACHUSETTS
.B)OARD OF HEALTH
......:% ®G ®V.------ .OF ......
,Y�}T'/
, ppliration -fur Miivooal Endo Ton.itrnrtiun Vrrntit
Application is hereby'made for a Permit to Construct (4-500"Or Repair ( ) an Individual Sewage Disposal
System at:
Location - Addressy or Lot No.
•l ----------aklw. _4�-------------------------
�i�,✓ ..7-r..---------
yy� /� Own r `i
- Addr &;1
Installer Address
Type of Building Size Lot 4652- --- _�-__Sq. feet
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.
lions.
WSeptic Tank — Liquid capacity4"..gallons Length(f.'_t_- WidthAY"2"._ Diameter________________ Deptll.457_ v..
x Disposal Trench —No - ____________________ Width -------------------- Total Length____---______--._ Total leaching area -------------------- sq. ft.
Seepage Pit No ..... ,%------------ Diametera_.$'-.O- Depth belowinlet.Ct'�__ _. Total leach--00--��-----
Z Other Distribution box Dosing tank ( �,�
a Percolation Test Results Performed b f%1._. _ � _ f%. Date... �Cr _
Test Pit No. 1__. _minutes per inch Depth of rest Pit./_;V _ _._.. Depth to ground water ._____-.____..
f� Test Pit No. 2................minutes per inch Depth of Test Pit ------ _............. Depth to ground water __._--.-_____-_-____-.
t� • -•------------•--
De� ption of Soil - ' fi t,�7%` - �--- Ca�L j ----- '- --
- -------------
V c _.. 1 AW.4 .'moi CZ---------- ------------------------ ------------------------
W
V Nature of Repairs or Alterations —Answer when applicable ------ _---------------- _----------------------------------------------------- .------------------
---------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Agreement :
The undersi n a es to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 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 G✓= ---------
Date
Application Disapproved for the following reasons: ------------------------------------------------------ -.........................................................
........................................................................ ----------------•----------•-----------------------------------------------------•---------------------.--•----- •--•-----
Date
PermitNo ......................................................... Issued ..............................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
tW?�....... OF......... .'. ::d�,. f.... ... i'.:-.:.. %"
Tntifiratr of TOntphattrr
THIS IS TO CERTIFY, That the Individual_ Sewage Disposal System constructed (/,,)'o Repaired ( )
r Installer
at
has been installed in accordance with the provisions of Article XI of Tl tate Sanitary Coe as described in the
application for Disposal Works Construction Permit No.___.____._' _1-___• dated .... ............
THE ISSUANCE OF THIS CERTIFICATE SHALL i610T BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. �j�''
DATE .............. *Z'Q- 7-/ ---•----•-------------------- Inspector ✓-•rr-�----�'�'� _/. ...................