HomeMy WebLinkAboutApp-Permit-ComplianceNO.S!�:3. 3D . -
THE
THE COMMONWEALTH OF MASSACHUSETTS
� BOARD,j OF HEALTH
14W..........................0F...-T.R IPi?..............................................................
Appliration for Disposal Works Tons rur#iun f irrmit
Application is hereb made for a Permit to Construct
System at:
.....,.�../Q�.�..//��...____... p� �a n�/�A ess. �..................
(L.. ........._...................................
Owner
..-• --- ... -
Installer
Type of Building
Dwelling — No
Other — Type
Oth
r
) or Repair (X an Individual Sewage Disposal .
.......... ..-��...._. _
Lot Np.
...._.� T ......or.f#IA ...............------
- ddress
4 Qom..-----.�1'� ►.... ..../�
Address
Size Lot ............................ Sq. feet
. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
I.. ......---•----------•--••----------------------------•.---------------•••--••......•--...............................................................
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 ........................
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Descriptionof Soil ............................................................................................
-----------------------------------•----------.....-----.----------•--------------•--------------------.-----------•----------------------------•------------------- ._.._.. --
Nature of Repairs or Alterations - Answer when applicable.�d��..... hoc......../�? 4Z-'(- ..ate
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 Compliance has binuAd by the)qard of health.
Application Approved By.....�!
Application Disapproved for the
Permit No. V_`_...3 / ...........................
Date
THE COMMONWEALTH OF MASSACHUSETTS
1 d _..._ ---
a _�,�------
1997 Date
BOARDYfi.ge�vurfl
OF HEALTH
IOWA) ......OF.. ......................
Trrxifiratr of Toutpliaurr
'HIS IS TO CITIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (X)
I:rl... �.MiZXI 6716L- e.�s-------------------------
Anstaller
at?..(_.......................................
has been installed in accordance with the provisions of T TLF, 5 pf The State SanitaryJ� e s de:icri ed�in the
application for Dis osal Works Construction Permit No.i�_2.V .---•.-----•-------- datedU-__ -- - b,_-!0 it
PP P f ¢ .-•---•---......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A Cs RARTEE THAT THE
SYSTE W�__.FUNCTIONSATISFACTORY.
DATE -? ---------------•---
Inspecto_. .........................