HomeMy WebLinkAboutApp-Permit-ComplianceNo... :...�J..3 Fims.. � z ........
THE COMMONWEALTH OF MASSACHUSETTS
OARD OF HEALTH
.... OF ................... .................. . ............... ......................
Appliration for Disposal larksA�®rRepair
ntrn.�iun 1rrmit
Application is hereby made for a Permit to Construct ( ( ) an Individual Sewage Disposal
S stem at*
Location - Address or Lot No.
Owner Address
•----•------------ +..._.. -.....-• ---�/
---------•---0---------------..
•.--- ---._..
►"� Installer Address � 3 �--_S feet
Type of Buildin—g............. Z— Size Lot ........... ............. q.
Dwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( �
p, Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfix ures-----------------------------------.----------------------------••--------------a-------------.•--------
d Design Flow ............. •-------��Dgallons per Pe er� e�d : Total ,Y�fipw........................................... s•l/
Ri Septic Tank —Liquid' capacity/ Ions Length F'_.--._.... Width_......<_....__ Diameter ................ Depth.-. �....
x.3... _
Disposal Trench — No . .................... Width .................... Total Length .......... .Total leaching area ... _ . sq. ft.
Seepage Pit No ---------- /-__-----. D ........ CZ—.. Depth below inlet................ Total leaching area.................sq. ft.
Z Other Distribution box (m Dosing tank ( _3> �7 /e �2
~' Percolation Test Results Performed by ----_-----_- -/�--..:.-=.-.C./-----�--./.-----------_..._..__. Date......�... -------
Test Pit No. 1L_ 2-.... minutes per inch Depth of Test Pit.._. / .. Depth to ground water_._..__. Z:_,...
fs, Test Pit No. 2 ----------------minutes per inch Depth of Test Pit .................... Depth to ground water --_--_---------------
................................................................ ..
....---••-----•---------
Descrl tion of Soil--------------��d - r�
45;4z '`f>------------------------------------------------------------------•----------------------------------------------- ------------------------------------•-----•-------------------
w----------------•-------------•------------••....-----...-----------------•------------•------•--•---------•-••-••-----------••----•-•--------------••-•...------....--•----•----..._....------------•--
UNature 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 TIT11 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i sued by the board of health.
Signed r� J`l_ � f 1✓. ----------•-------.. 7- 1— .. /
-------- ] - -
Application Approved By ....
P"K::,k C -------•--------___-----------------._.-- ••-21Date
.7.1.
'1 -------•te
Application Disapproved for the following reasons------------------------------------------•------•---------_......_---------------------..__.._-----------------
...............................••---------•-•-------...-•-••--------•--•------------•......----.....---------------.....----------------•-•------••----------- ••-••----•-•-
Date
zl I�d�
Permit No. -.................................................. Issued - --- r Daft
- ._........_.........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........: ........................ �j...............................................................................
Tafif irate of Tomplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed O or Repaired ( )
by------A4----Cc-_Qw"-------------------••---•----........--------------------•--------....---•--•-----...------....... -----...---•-----............--•-----------•------
Installer
at---- - ---- C-C-Qr-�-----C_k — ------------------------------------------------------ .............. ..... ---•- • -----------
has been installen accordance with the provisions of TITLE 5 of The State Sanitary Cod �." as described in the
application for Disposal Works Construction Permit No. `_ X - - ------------- dated.:_.__s�!.aL- 3__ ..___._-.......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY
DATE- . �.j .? .....? :? --- ------ ------ ------------ -- ------ Inspector....: = - -...
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