HomeMy WebLinkAboutApp-Permit-ComplianceNo.._GI. Fns..r,-DS.............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
........... oWN......... OF......
Appliratiou for Displaial Works Tonstrnrtiun ramit
Application is hereby made for a Permit to Construct ()<) or Repair ( ) an Individual Sewage Disposal
i �Fi�ystem at:
�2 Z 0,4P7 IM Y Rog);?, l� P �a
. -• - ��'.............•--------•----•-------------------�------ I!S%ft?/ bF--------t�.. - ..__........-----
o ation - Address Lot No.
If- rAIAIIf
caner Address
............................•-•---•--•------
Installer Address ..
Type of Building Size Lot.13..ur__§__7..Sq. feet
aDwelling —No. of Bedrooms ___..._ . �3 ............................... Expansion Attic ( ) Garbage Grinder ( )
p, Other —Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures _______________________________ _ _
W Design Flow ........................... S7,67 per person per day. Total daily flow ...................... 322 ......... gallons.
WSeptic Tank—Liquid capacity/_O00--gallons Length.$. -G..___ `Vidth4_:A4____ Diameter ......:......... Depth ..
x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ..... j --------- _____ Diameter.4../.f_ z_'.. Depth below inlet .... Total leaching area. -A..0.4 ..sq. ft.
Z Other Distribution box () Dosing tank �y
'-' Percolation Test Results Performed by ....... --�Tf:4T...AR%......... Date___
as Test Pit No. 1LAW..2,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... � 1 �-*t ................
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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 LI^.."
p of the State Sanitary Code — e undersi ned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by e a o Iealth.
r
Sig-..... ..._JL................................... ----- .... ....D
e
Application Approved BY v�- - ----------- �--------------------------- .--....... .....--....
Date
Application Disapprove& r the following reasons: ................................................................... ..........................................
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Date
PermitNo ......................................................... Issued _.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
TrriifiraU of TOutpliana
THIS IS, CERT FY, That the Individual Sewage, Disposal System constructed (,,,e) or Repaired ( )
Installer 1 .,
at d f1 •%^ -��------------•--C T--------L� J ,',� l� t 1 ' -
has been installed in accordance with the provisions of TITL oft
/The State Sanitary Code as d cri d in the
application for Disposal Works Construction Permit No.......�........ dated ---------- ... .._ .. ___. ..............
TIME ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUAR NTE FIAT THE
SYSTEM WILL FPf4CT1J0N SATISFACTORY.
DATE- Inspec r