HomeMy WebLinkAboutApp-Permit-ComplianceFmc.A/5 .......... .
THE COMMONWEALTH OF MASSACHUSETTS
------j _ BOAR OF HEALTH
.......................... OF......!...2 19D1!1T.ff._...........__.._..._......-•----......................--•--
Appl ration for Ropmal Varks Tons rur#iun Frruti#
Application is hereby made for a Permit to Construct ( ) or Repair (/),-an Individual Sewage Disposal
System at : M c
• ''aa*-7r,............r...--.-- .. .... Z T _ S _._..... rn. :..._.1.......------...------•-----.......
_J__ /j Locat,���%- or Lot No.
Owner
..............................................................................
Address
Installer Address
Type"L.Bmlding Size Lot ............................ Sq. feet
Dwellin No. of Bedrooms._ --------- S .............................Expansion Attic (/?%m Garbage Grinder Y14
ther —Type of Building __ --- No. of persons..... ; -:............... Showers (,I — Cafeteria W4
Otherfixtures ---•-----•-•-----•----•••--•--•••--•-----•--•-•........-----------------------------------------------------•-.....---.............-•-------......----
Design Flow .... :�� ........................gallons per person per day. Total daily flow ......... .T 3 .......................gallons.
Septic Tank — Liq id capacity/O.Op--gallons Length ................ Width ................ Diameter.......--....... Depth ................
Disposal Trench — . -•------------ -- Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No.l.i
_._.____ i eter.................... Depth below inlet.................._. Total leaching area..... ---._........sq. ft.
Other Distributionox ( 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 ........................
Description of Soil ....................................
-•---•-----------------.............
Na;ure gf Repairs or
Agreement: {�
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITLZ 5 of the State Sanitary Co e — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee iugfty t e oard of health.
Sied--•-- - -- •---------------------------------------------------
Application
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t
ApplicationApproved By-••• ................. -------------•------------------------------------ ----. .
ate
Application Disapproved for the following reg&ons: ...... I------------------------------------------------------------------------------------------------------- -
..----•-------------•----•-•--•------------- ------•-----------•-------------------------•-------------.._...--------------------------.--•-------• 8 -----•--•'Date----------•--•
Permit No.m.- 7 .................................... Issued
ate
THE COMMONWEALTH OF MASSACHUSETTS
BOAR OF HEALTH
L�.v�;�!v.......................... O F..... ie' 4. u?7f......................................................
_ (Irr#ifiratr of Toutplittnrr
THI ItS TO �ER�FYThat the •ndividu- �-,,Sewage Disposal System constructed ( ) or Repaired (rr\)
by.........J\_.. _ L...�, ---..............................................._........--
Installer�'���
...�
has been installed in accordance with the proviZons of T Irrrjjof he State Sanitary Codc��s d ;cr' ed ' the
application for Disposal Works Construction Permit No.Y.___�'I_l_---------------------- dated..-.,, ..........�.���'.��_..:.......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED ASLAA'' UARANTEE THAT THE
SYSTIiI WILL FU CT ON SATISFACTORY.
DATE.....f_.... L., -Inspector-_.
� .... .._