HomeMy WebLinkAboutApp-Permit-ComplianceF--
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
QW-�................OF.
Appliration for 14opoal Workv Tonstrurtion 11amit
Application is hereby made for a Permit to Construct (IQ or Repair ( ) an Individual Sewage Disposal
Location - Address or Lot No.
.....
Owner Address
W ' ` .........5 r----------------------------------•---..._
........... -------- i o ... ............
Installer Address
Type of Building Size Lot ...
... Sq. feet-
- Dwelling —No. of Bedrooms ........5 ............
------
-------------- Expansion Attic ( ) Garbage Grinder ( )
p, Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Q, Other fixtures -----•-----------•-------------- . . .--
W Design Flow........... 55 55 ......................... per person Qe�r day. Total dai�l}` flow..............._ ... ........ .....g�llo
WSeptic Tank—Liquid capacity.�oballons Length --- Width____.!'2-._ Diameter ................ Depth_.G_�.._...
x Disposal Trench — No ..................... Width -1- __._ --------
Total Length ......._.t_.__.. Total leaching area___-..__.__.__._... sq. ft.
Seepage Pit No ------- A............ Diameter..._ • Depth below inlet --- -Total leaching area.42. Z- GI D
Z Other Distribution box (�) Dosing ( )
�+ �w1cv5 ' -5' Date $
a Percolation Test Results Performed by- _.T....Q................ } ..._ .......i.._.._.___....... _ � ..___..............
Test Pit No. 1.-- 5 2=.minutes per inch Depth of Test Pit .... .�'�'...__ Depth to ground water.... �?
•� �.;ncrsr ..... fed
Test Pit No. 2................minutes per inch Depth of Test Pit ----- .��_._.. Depth to ground water ........................
YP.............. ...1--•-•------ •--ir------•------- g-----------• i ----
o 1; o - 3� � oar,,, � � ..... _.....--
n 5 ; ..... _ 132 r,n e �....
Descri do�'j of Soil---�'-- •'----•--•------•................................... �
1 •Z, - i s cX eaV1 �e . 'Sah4 -i'. N . 2 : o - 2. l -cl --- - v►, V. ��� .� 4'Z. lit
V------.... --t-- •• ..._ I ............... :� _..... ........ t C Y�e�PIC"1
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......................... I
---- •--------•-•-------•---•---•------------ --------------
U 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 bee i d by the b rd health.
X Signed---- -- .... --- --------------------- 1 - ®..!
VDae
Application Approved By------ ...... •----•------ ----------------•--.......-----•---•-------------------•----- -- •---------------
Application Disapproved for the following easons----------------------•---•----------------------------------------•----------------------------•---------•••----
-----------------------------------------------------------------------------------------------------------------•---------------------•---•-----•-------------------••--•------------•---•----
C� - - -------.Date
Permit No ----- L�_.1__6._ ....................... Issued .......... -u-1!
Dace ......
4
.THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
Trr tifirFa#r of Tontplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (X or Repaired ( ) !
I!
Installer
at---! �----------- MA----- --------- �-_------------------------------------------------------------------------------------------------------- -------
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 CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE--------- I IJ 4 -------------------------------------------- Inspector....Q44S.D__Q......----------------•........_....--