HomeMy WebLinkAboutApp-Permit-Compliancer?....'
No.. . _
82....313 Fps.. ,�..................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
Appliratinn for Disposal Works Toustrurtinnamit
Application is hereby made for a Permit to Construct
System at:
......
....
Location - Ad ress
..._... .......
Installer
( C- -ef Repair ( ) an Individual Sewage Disposal
. ...... �'.ec...� -- c....-------MRE:: 1 b D F 10l
or LotNo.
Address
.... .......... .... .................
Address 74,
Type of Building Size Lot... '" ___ 3q. 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 Aow.......�`�r_�_._.................. gallons.
Septic Tank—Liquid capacitallons Length ......_. Width .... '�,�_..... Diameter ................ Depth ---
Disposal Trench — No . .................... Width -------- ........... Total Length .................... Total leaching area --__---------------sq. ft.
Seepage Pit No...__ ---------- Di eter.... /. ...... Depth below inlet..... ....-... Total leaching area -__3 . �-sq. ft.
Other Distribution box ( Dosing t )
Percolation Test Results Performed by..-, .. %:'.)------------------- Date ...l�........ ��`�
Test Pit No. 1 ....... inutes per in Depth of Test Pit..��` Depth to ground water .... .
------------
Test Pit No. 2---.'��triinutes per in h Depth of Test Pit../Y' Depth to ground water ------ .
Descripti of Soil ✓ e ' /P rV . ..�
'l -
Nature of Repairs or Alterations — Answer when applicable ------------------ /Y
•----------------------------------------------------------•---------------.....------•-•-----------------------------------------•---------------•--•-----------------..............................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE, 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliant s een issu by the health.
Signed --• ............. -------•-z-.. /,� �
Date
Application Approved By. ----��=-----
•-
Date
Application Disapproved for the following reasons--------------------------------------------------------•-------------------------------------------------
--------------------•-------....--------.....------------------------------....--•----------------------------------------•--------------•--------------------------•--------------------------•
Date
Permit No._ 2__ -3 ?.a------------------•-------- Issued ......_
-----•-----------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...... ... r.......« ..........OF ....... ...... ......... r... . ...........................
AT
wrrftfirFatr of Toutplianrr
THIS IS TO CERTIFY, That the Indiv
ual Sewage Disposal System constructed ("-) or Repaired ( )
by ••- ---- .--- . ----•--•=-- .................. --• ---- -------------------------------•------------
/r t 1
. ...................... e_.___. .
Install6r 3___ .._...... ._.. _._. _----
at......................... ....._- ._. !. _------
has been installed in accordance with the provisions of TITLE, 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.___.;...2 /- i ----------- dated ___._ �.... r� .Z .................
THE ISSUANCE OF THIS CERTIFICATE SHALL NO STRU S A GUARANTEE AT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.... •�r`= = '�•. ----�-............................. InsP -•------------.......... . --- ----...... ................... -•------•--.