HomeMy WebLinkAboutApp-Permit-ComplianceNo..�.'..'.! FE$......t 5
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appliratiutt for 14spuiial Works Toustrurtion rumit
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 n issued by the board of health.
Signed------------------•••--.......-•---------•----•-•------•----•-•-----•••-------•--- -... --------
Application Approved BY ...............•-- --. ------...---•------•-----------------------------------------------
Dat
Application Disapproved for the fol
ollowi reason ---------------------------------------•
Permit No .... ----1} - ---s L- ---
---------------------------------------------------------------------------
at
Issued--------------- ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH •C �.�s�9Ll�
.......................................... O F ................................................. ....................................
Tntifiratr of Toutplittttrr
THIS TD CER, JFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by-------------- -10-0'42L' =l----•---- 2u 2.....---•--------iii..............................................................................................
at. r461'. .7------------- i �' r!l.--G -d'n `S''-� �� 2
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 ......................................... dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTE AT THE
SYSTEMA WILL F NCT N SATISFACTORY.
.�
DATE.-----.Z�- -...--/---------------------------------------- Inspector -•--- •. •--- ---- -...............
Application is hereby made for a Permit to Construct or Repair
( ) an Individual Sewage Disposal
System at:
'
Location -Address
or Lot No.
W
a
...................... _......................................................................... ......................_.....
Owner
................ ........... .. ----------
^........ ......... ..-•--- 2 0p.----....---------••-•-------••-----•--•-•---------•-----•------................................................
......--
Address
in
Installer
Type of Building
Address
Size Lot .... /-/',.. 2/4.Sq. feet
P4
Dwelling—No. of Bedrooms .............. �......................... Expansion Attic
( ) Garbage Grinder ( )
P4
Other —Type e of Building ............................ No. of persons.............._.........__..
Showers Cafeteria ( )
Other fixtures ..
W
Design Flow..............J'.........................--..gallons per person per day. Total daill flow___.____.__ _��' -----------_-gallons.
Tank Liquid' '._
WSeptic
— capacity/AOd.gallons Length_.: Width...... `....
Diameter ................ Depth-----------
.S_.Disposal
DisposalTrench — No ..................... Width .................... Total Length ...............
Total leaching area .................... sq. ft.
Seepage Pit No ........ ........... Diameter._/0..6 '_ Depth below inlet ....... 6......... Total leaching area-4"'-��c_�%s�. 6 -PP
Z
Other Distribution box (,A<) Dosing tank
Percolation
a
Test Results Performed r...1N�
.._. Date....•.:.: --/4._'8 1-----•-
Test Pit No. 1--- C. ._minutes per inch Depth of Test Pit../ 4¢-- `"._
Depth to ground water! T 4iey -_
G4
Test Pit No. 2................minutes per inch Depth of Test Pit._.____.___._..____.
.
v .V 4B
Depth to ground waterGD..___..__.._...._.
•---•-------------------
O
------•--------.....-----...._......------------... .
Description of Soil ---------- 4K4E]? ------•---
......... •-----•---•-----•---------•--.....----....---•-•----•-------------•••-•
U-
W
.--------------------------------••----•--•-----...----........-----•------.....-------------•-----------••-----------------•------•-•------...-------------•----.....•-----.....-----•------------•-----
V
Nature 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 TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has n issued by the board of health.
Signed------------------•••--.......-•---------•----•-•------•----•-•-----•••-------•--- -... --------
Application Approved BY ...............•-- --. ------...---•------•-----------------------------------------------
Dat
Application Disapproved for the fol
ollowi reason ---------------------------------------•
Permit No .... ----1} - ---s L- ---
---------------------------------------------------------------------------
at
Issued--------------- ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH •C �.�s�9Ll�
.......................................... O F ................................................. ....................................
Tntifiratr of Toutplittttrr
THIS TD CER, JFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by-------------- -10-0'42L' =l----•---- 2u 2.....---•--------iii..............................................................................................
at. r461'. .7------------- i �' r!l.--G -d'n `S''-� �� 2
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 ......................................... dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTE AT THE
SYSTEMA WILL F NCT N SATISFACTORY.
.�
DATE.-----.Z�- -...--/---------------------------------------- Inspector -•--- •. •--- ---- -...............