HomeMy WebLinkAboutApp-Permit-ComplianceNo............. '...
FRs........1...
.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Apli irution for Uiopusal Works Tonstrur#iuu .rrutit
Application is hereby made for a Permit to Construct ( ) or Repair (k<an Individual Sewage Disposal
System at:
f % Locatio� dresjs 1� C /� or I of No.
..........�....vJf!��: 1 AM- o d f ._..._ sl /.�A ...............................................
�.: -----
Insta er Address
Type of Building Size Lot ............................ Sq. feet
Dwelling — No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other —Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures .-------•--------------------------------------------------------------------•---•---_----
Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid capacity ............ gallons Length ................ Width ................ Diameter... ............. Depth ................
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area -------------------- sq. ft.
Seepage Pit No ---_--------------- Diameter .................... Depth below inlet ..................... Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation 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 ........................
r----•---•--•--•--------------••-•--•••-•---•--•----•••---•-•-----•-•---------...-•-•---•---•--...•---.........................................................
ODescription of Soil ........................................................................................................................................................................
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W------------------------------------------------•------------------ ----------------------------------------------------•- t'
U Nature of Repairs or Alterations — Answer when applicable...s?�-� � _`------: __._ _�____�6A .............................
..................... n•— A4)j)_....... ........ ley . ...........................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITI..E 5 of the State Sanitary bode — The undersigned furt4anot to place the system in
operation until a Certificate of Compliance has en issu d by the boar of heaSigne -jx --- - .. .--•- ' --------- -- •-- .... .
Application Approved BY ...........t
e.
................................................ .
Date
Application Disapproved for the f ollowi 'g reasons: --••--••---••--••••----•--•----••---••.................................. --••----•-••......................._
--•--•---•-••-•--------------•---•-------•---------•---------------••----------------•----------......---•----•••----------••-••-•--•••......--••----••--•-•-------•-•••.-------
Date
Permit No ..... .fC7 - ---------
�/
_ _✓� J Issued•--•--.... n� ,� ••
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
............... OF.........�:M... ..................
Tirrtifirat a of Tourplitturr
THIS IS TO CERT FY That the Ind* idual Sewage Disposal System constructed ( ) or Repaired (�)�
�
j� �staller
has been installed •n accordance with the provisions of TITLES 5 of The_$tate Sanitary Code s des ribed in the
application for Disposal Works Construction Permit No ------- K.�._------- dated ------ -------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTIO SATISFACTORY.
DATE------.... � Inspector :.. :... .......-•--•-.....------• •••---