HomeMy WebLinkAboutApp-Permit-ComplianceNo.... Fmc... �L ..�...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......................................OF.....---......---......................--------- .........................................
Appliration for Uiivu-aal Works Tongtrurtinn Fautit
Application is hereby made for a Permit to Construct) or Repair ( ) an Individual Sewage Disposal
stem at:
��#gay �-� -s- P 3g
G M- >�
Q.._._L..o_.c.ation- Address ory1Lot No.
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O7..�l..+�h.ld��%•��lp B!�j _J%
�
ddress
-------------------------
Installer Address
a X= c ------ ��
Type of Building Size Lot... �_,._---.-./___.___Sq. feet
U Dwelling —No. of Bedrooms____________ ___________________________Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Pa Other fixtures -------------------------------- -
W Design Flow -------------------------------------------- gallons per person per day. Total daily flow _._..._ .. �r�-_.-_.._.---_-_- ..-.._gallons.
G; Septic Tank —Liquid capacity. QQ0.0_gallons Length___- Ze....... Width-__ S_ ....... Diameter ................ Depth. 4__'.......
W------ Width .................... Total Length ---------- ___._._--- Total leaching area. 3 Y".�Z..sq. ft.
x Disposal Trench — No . ..............
Seepage Pit No ..... J----______--- Diameter ......._.--- .___. Depth below inlet-. ... Total leaching area.................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Z -Date.--5zar z� i5i
Percolation Test Results Performed by-_...:�^r __._�` _ __ ���.__...!� �_.....__. .....:..... ......1.. _ma------ �_.
,aa Test Pit No. 1 � _spa.. Zminutes per inch Depth of Test Pit .... !_: ..__.. Depth to ground water O?±(ceez.�
(i Test Pit No. 2................minutes per inch Depth of Test Pit ________-__ -----_-- Depth to ground water ........................
--•-•--••••------••--------•----•---••-•-••-_--••-•••••-••-•••-......---••-......'-•---'-'----'---.........................................................
O Description of Soil.` Ge+A?-i__-Ie .Sz�>3 _Sv j L` '�'-----G.-- ...............................
w
VNature 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 : T?. y g = g P Y
5 of the State Sanitary Code —The undersigned further agrees not to lace the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed--------- -------- Z�- Q&K4— =,. ....................................
Date
Application Approved By ........................ ----...e-- --------------- 7`G.
Date
Application Disapproved for the following reasons: ................................................................................................................
....••--•-•••••---•-•-••-•------•--•----•-•----•--•••---••-•-••--•••--•-----•-•-•-••-•---•-'•-•.......... ...•--•-------•-•------•----••-•--•-----•----•--•-•--••-------•------••-••---•••----•••----•-•-
Date
PermitNo------ -------------------------------------------------- Issued- -------------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........................................_0F .....................................................................................
Cprrtifiratr of Toutpliatta
THIS IS jT9 CERTIFY, That the Individual Sewage Disposal System constructed ( K) or Repaired ( )
b................... �... ! ./7 ..................... -------.._.._---Inst-- -- ------------ .----- ----------*-----------------------*-------------------
at................... i ,1 a---•--��--�------------�`.... ,�-------------- ........................................
has been installed in accordance with the provis ons of TIT r 5 of The State Sanitary de, d ^cribed in the
application for Disposal Works Construction Permit No ------- �' -.� dated_._.___. �a�se`�________________
r
TIME ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector ------------------------------------------------------------------------------------