HomeMy WebLinkAboutApp-Permit-ComplianceNo------------------------- F:m$..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....�•.v.A1................. OF...... Y.4 Iparix---------------------------------•------
Applira tion for Disposal Works Tonstrnrtion 1phrmit
Application is hereby made for a Permit to Construct ( L -)--or Repair ( ) an Individual Sewage Disposal
System at:
....Vj0F?.9.f.L..<l... I.. -------------- ]"- _ ----------------------------------------
Location - Address or Lot No.
Owner Address
Installer Address
Type of Building Size Lot.DO5------ Sq. feet
Dwelling —No. of Bedrooms .------_ �...............................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Other fixtures ------------- ----------- -----------
Design Flow ------------ MG -----------------------gallons per -pessan per day. Total daily flow ............¢1".��---------------------- gallons.
Septic Tank — Liquid' capacity/tVa .gallons Length..J.4- L -.- Width.¢ _-lG... Diameter---------------- Depth. -ter
Disposal Trench — No..../ .............. Width .... /Z.'....... Total Length..... aZ........ Total leaching area...... `f0d --- sq. ft.
Seepage Pit No ..................... Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box ( of Dosin ank
Percolation Test Results Performed by .. Date--__7?9__Y..---r-_-_._..
i
Test Pit No. 1.. 1 ...... minutes per inch Depth of Test Pit..11-_ _ �..._.. Depth to ground water ...... Q.............
Test Pit No. 2._4 L...... minutes per inch Depth of Test Pit ----- 9........... Depth to ground water .......
Description of Soil. --1 .... _-4-.': ��------.T-.%?•..........
f._.
Nature of Repairs or Alterations — Answer when applicable ................................
.........................................
..................................... -..................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescA—u
Sewage Disposal S stem in accordance with
the provisions of TIT LS 5 of the State Sanitary Coder'
ned rthr of to place the sys ein
operation until a Certificate of Compliance has bee 'of cal h. �G
In
Signed ------ ------------------------------------i..... '----=--------------------- --- e � ------
ApplicationApproved By........................••--------•---...-•----.....----•---...--------------------•-------------- ..........................
Date
Application Disapproved for the following reasons: ..................................................................................................
....................•------------•--------•-•--------------.....---......------------------•---------•--- --............---------------------.....-------•---•------.......---------•------
Date
PermitNo ......................................................... Issued .......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .............................................................. I ......................
(Intifiratr of Tontplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by----------------------------------------------------------------------------------------------------------
Installer
at..................................................................................................... ---------------------------------...-----......----------------------------.._..._-------------
has been installed in accordance with the provisions of TITIE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ......................................... dated.. ..............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector --------------------------------------------------------------..._-.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
No......................... FEE ........................
Disposal Works Tonstrurtion Frrutit
Permission is hereby granted ..............................................................................................................................................
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
atNo...............................................................................................................................................................................................
Street
as shown on the application for Disposal Works Construction Permit No ..................... Dated ..........................................
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Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS