HomeMy WebLinkAboutApp-Permit-ComplianceNo.... -4 R$......
THE COMMONWEALTH OF MASSACHUSETTS
r
BOARD OF HEALTH
........................................... OF ............. r ...........................................
Applirtttioxt fur 14spouttl Warks Tonstrnrtian Frrmit
Application is hereby made for a Permit to Construct
System at:
..----•........................
—7Locati Address
......... 0._....----: r .:l: T cs'm..........................
Owner
fit' %✓ -10----------------------------------------------
Installer
Type of Building
Dwelling — No
Other — Type
Oth
or Repair (�() an Individual Sewage Disposal
.................................•-----.....---------------------.............................._..
orLo.
a4�rt._ ot ..................................
Acldres.s
ti�tst
_a._..._..._li/'rnau�
--� ...--�........... ...............
Address
Size Lot ............................ Sq. feet
. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
erfixtures ------------------------------------------------------...-----------....--......------------...----------------....--------..._....---.....-----------
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. f -
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. I................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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.
Description of Soil...--------••--------------- -- ---�L__------------� L------�
................•---_......-------------•-----------------•-----._._........___..._...__-----•---•---____.....---•-.._...-----------•-------------------•-----------__..
-•-------•-------------•--•------•----------------•--•-•-•--------------------•---........--•---•-- ---•--•------ •---_...---•••---......_.... ......_------- ----•
Nature of Repairs or Alterations — Answer when plicable.... �1?,S_�` /� ____....1 _...._ �l4QfJ___..._ a _1..... S�yA.
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I...1?!�l �� i_tru �ia�n..._�D �. t------I-----..la K.(n l e �: t� � � � �- is ��_ l- h �------.... »-.-------------------------
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLZ 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been, issued ky t�F board of health.
Application Approved By
---i:�-2i-3
-...._.._. ate
- -•-•--•y----
Date
Application Disapproved for the f ollowi reasons- ------ ------------------•-•---•---..__...-------------------------------------•------•-----_...••--•-----------
....-•----------•-••---•----------•-••-----•----------.....-. ..-----•------••---.._..-•----.._..__...------•-----••
Permit No. -..5__._.._... .._.. Issued .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Trrtiftratr of Tomphaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (o ff
by......... __--•----__z9&k.2--------------------------------------------------------•-•---------•-------•------_________ --••---------------•--_-_____-_______--
%J n 1�Install,
at ...... �.a�......... L.Sc1J_- -'c.. i----�14.%�'S�axfy -----------------------•-
has been installed in accordance with the provisions of TITLB 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 GUARANTEE THAT T/
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................................................................... Inspector ............................................................................