HomeMy WebLinkAboutApp-Permit-ComplianceNo.._.a
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. OF.....Y4011,00.1; i^. / _----••-•---••.............................
Appliration for Disposal Works Toustrur#iuu 1hrutit
Application is hereby made for a Permit to Construct (r/) or Repair ( ) an Individual Sewage Disposal
System a
ocation - Addresso
O er�, /�dd ss
InsyA4.
ler Address
dType of Building Size Lot_ /____..Sq. feet
aDwelling —No. of Bedrooms._... ................................Expansion Attic ( ) Garbage Grinder 07
PL, Other — Type of Building ............................ No. of persons ....... __-----____.__..-__-. Showers ( ) — Cafeteria ( )
Other fixtures -------------
Desi n Flow ......... ................. ...•__gallons per er day. Total daily flow_-__.__-.__A�--------------------gallons. „y
W •g�, g iy , "
WSeptic Tank — Liquid capacity �A�.gallons Length_l.._._........_Width...f .___.. Diameter ................ Depth_.47...�.
x Disposal Trench — No. _.._.._._•-•-__----• Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ..................... Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Z Other Distribution box ( Plfo' Dosing tt k ( )� /
Percolation Test Results Performed by. .__4 s....
�__��l�R�...!_� �._.___._..__ Date.__.����.� .._.-��---
Test Pit No. 1 ... AA .... minutes per inch Depth of Test Pit../ ....... Depth to ground water ... `A9..........
Test Pit No. 2_____________Lch, D,%4h of Tet ' Pit ------- Depth to ground water ........................
...... •.... tt_(.!t=S ----------------------
U
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 TITIL 5 of the State Sanitary Code he ersigned further agrees o lace the system in
operation until a Certificate of Compliance has be issu b ea /
Signe..... . •. =•... ----- ..... ----- •-•---•--• �� -_D . _..
a e�
Application Approved By-•-••• • .. •-•----••.....................••-••-----•--•-•-•-.....----•-••-----•-----•-�.-1�' Da
t - e az -------
Application Disapproved for t e f oll ing easons: ---••-•••-•-•••-••-••---••-•-----•-----••••••--•-•-•--•-•--....•-••••----•---•--••-•-••......---•-•-•-•------•-
........................................................... •-------•••-•-••--•-----•-•---•--•-----••••----••----••-••-----•---•--•----•--•---••---•--•---•-----•-••-•-•-•--•---•...D
�,/ 7/ ---------•-Date•
Permit No.__..4_................ v.___ - Issued�-�- ..8 --
D
THE COMMONWEALTH OF MASSACHUSETTS_
BOARD OF HEALTH
...........................OF.Y 0 4.4.......:..................: .........:
Trrfifiratr of fir mpliaurle
�HI T ERTIFY, That the Individual Sewage Disposal S7stem constructed O') or Repaired ( )
.q
l�(iE �i12S
by .......................•. •-----•----•--•-
/_C�O� Installer
���------/-�--.....�........---I.11_..__(-nl.----••-----!�----------•------------------------------------------------------------•----....--•------------...-------the
has been installed in accordance with the provisions of T�� ; f The State Sanitar Co aa de - r' in
application for Disposal Works Construction Permit No._. .. .................. dated_ - ...kNTEE
As .....-_......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS GU THAT THE
SYSTE ILL NC®®TIOI} SATISFACTORY. ie / R �A fl ��►7 FROM
DAT Ly.4_�--•-•-----•-------------------- Inspector._ A!r1Sf _ SCyN�UO .1NC .-._...----.------------•-