HomeMy WebLinkAboutApp-Permit-ComplianceNo ..... ,'_�?.SACHUSETTFps....... S.. ....
THE CO EALTH OF MASS
a
BOARD
�pOF HEALTH
1-...d .'. [............ OF .... y gj'.l.o v*- --------------------------------------------
,�ppliration for Disposal Works Tontrurtion 11nmit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
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L ation - Add s or
.._.ail .h'. �e...1.1 `' --� gilt-... - S6)(_ 1273 Jc%�'i' �it0t �
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Owner Address
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Installer Address
Type of Building Size Lot.. _.. _ _..._._Sq. feet
Dwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons .......... _........... :..... Showers ( ) — Cafeteria ( )
Other fixtures..-----•---------•-------------•-•-•------------------.--•.-.--•-----••••---•-•-•--------•--•_-••--------.--------------------- ...
0- ---------------------
I on ._s_..Design Flow ...........................5. _.gallons per person per day. Total daily flow....................... 3Z......
Se tic Tank—Li uld ca acitY-�--gallons Len th.8_.G... Width_ -1o. Diameter ................ De th`
Disposal Trench — No ..................... Wi�tq-... .� ..__.__.. Total Length .................... Total leaching area --------------------sq. ft.
Seepage Pit No ----- I-______________ Diameter................... Depth below inlet...-..........._. Total leaching area.._.. —4 -._.sq. ft.
Other Distribution box (X) Dosin tank L
Percolation Test Results Performed by... G.►..s.................................... Date... .RP......__.
L e� c1
Test Pit No. 1___________�fJ _____minutes per inch Depth of Test Pit....%,�..�._ .... Depth to ground water_�Z.�2._..=_...__.
Test Pit No. 2 -------------_ minutes per inch Depth of Test Pit .................... Depth to ground water ........................
Description of Soil ��ir����JE L� ---- --4Jf--•-- -------------- - .....
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Nature of Repairs or Alterations — Answer when applicable_______________________________..........._.-_...._.._...................._.....................
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Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 5 of the State Sanitary Code —oTdersigned urther agrees not to place the system in
operation until a Certificate of Compliance has been issubo of ealth.
Sined.......---••- --• . -------------•--•-•-•--•-......•--• 0/2. . .............
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Application Approved ByB..... ------ ----- - ------------------------------------------------------------------- -----! 3Ai
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Application Disapproved for the following reasons--------------------------------------------------------•-------................................................
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j -----.--Date
Permit No.. 1---==�--•------------------------ Issued ------------ Z.4D /e . / ------
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
Tntifiratr of Tontplianrr
THIS IS T ;CERTIFX /That. the Individual Sewage Disposal System constructed ( or Repaired ( )
by - - f `' y ...----------------------------------------------
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taller
at-' = = - ..._... �= = !(...........................••-•----------•-
has been installed in accordance with the provisiovls of TIT l 5 f–The State Sanitary C/�RiANTEE
s d ybed in the
application for Disposal Works Construction Permit No.__...�............._____________•- dated ___.__-- .e__._-----•-----•-------.__
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A G THAT THE
SYSTEM WILL FUNON ATISFACTORY.
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............DATE ....... Inspector ................