HomeMy WebLinkAboutApp-Permit-Compliance� # No. � L3a_7_
Fxs......� .`�.._
THE COMMONWEALTH OF MASSACHUSETTS
,BOARD OF HEALTH
1.�%../v.._.....oF...... .. ...... ��a.0: ..........................
firtt Ilan
for Disp sal parks Tonstrnrtiun 1hrmit
Application is hereby made for a Permit to Construct ( ) or Repair(� L' an Individual Sewage Disposal
System at:
✓'t �-•--1•_-�.•^.off ss
........
.71 Loca io .- Addres yr. Lot No.
......... ........... _..........
J...�lf e
_ ...... •---_.. ......=....•..... ......................
Installer Address
...`.•3. •-- ..
-
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms ........... ...........................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures - ........ -.......................... -.................................................................................................................
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. ft.
Seepage Pit No ..................... Diameter ...................... Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tank( )
Percolation Test Results Performed by......................................................................... Date ...................... 0.................
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
....------•-----------------------------•--.._....----.._...------.......-•-•---•---•-----PP--•••--•---•---•--•----.%'` `�� �� -------------------------
NatNature
re of Repairs or Alterations 4nswer when a licable_/_' ... . ......... / _.I.D.Qd_
•---------•----------------------------------•--......_...-----•-•-...------•------------•--.._...
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIN 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been is ued by'' the board of hh_xe-alth
Sined..--- ........ . . .j....
at
- _ ..----Application Approved BY ••--•--•-•-------- --- 4o ate o
Application Disapproved for the following reasons:---•--.._...--•--•-•--------------------•------.....-------------------•---....-----------.............----...-
- Date
Permit No ...... 91__--.��_--7------------------ -------- Issued .............. jJ&.�(_. _s : ...........
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAI.,,.' H
OF...................`":.� --- ._.....-•---............_.
Tntifiratr of .>xntVlianrr
THIS IS TO CERTIFY, That the IndiyWual -Sewage Disposal System constructed ( ) or Repaired (k)
by47 --- 441...----•--•--------•-------------------------------------•---•-------------------------------------•-------
In�taller
at.......................................................... 7L- !. _._.. -_"- - ---------------------------------------.......-••--------------____--
has been installed in accordance with the provisions of TITS 5 of The State Sanitary Code ts described in the
application for Disposal Works Construction Permit No ....... _ :__ �-� .......... dated --------- tC1 _t_ _��.. ..................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION; SATISFACTORY.
DATE.........::.......... `---------...........---••-........_.. Inspector .;,..: ---.-_---......