HomeMy WebLinkAboutApp-Permit-ComplianceNo. :� ... & . FEB ........_
5-' 7 'Vq THE COMMONWEALTH OF MASSACHUSETTS
85--'V
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BOARD OF HEALTH
----........T.oWn................. OF .............. ennis.........................................................
Appliration for Disposal Works Tontritrtion fumit
Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal
System at:
-_ J2-314 Winslow Greg_.Rd_•________-West Yar same ......... LOQ. K� �n I EPS q _off__--.
-- --- .... --------. .. - - - --- --
Location - Address t o
Paul Robichaud ____.345 walnut Hi�.� lid Orange Ma 01364
- - - - • --... -- - - ---------------- -------------- -•--- .........--.............._..
Arthur Sears & Sons Inc 313 Hokum Rock Ref daressDennis
-•--........--•---------------•-----------•-•-•----•---•----•-----------------------•------------- ---...---•-----------.....--------------•---------............--------------------•---•-----------
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 ( )
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 ................................................
Test Pit No. 1................minutes per inch Depth of Test Pit .........
Test Pit No. 2 ----------------minutes per inch Depth of Test Pit .........
Description of Soil...
.-------------------••--....--_.....
Date.........................
Depth to ground water .........
Depth to ground water .........
------------------------------------------------------------------------------------------------------•----------•-------------•--------------------•--------------•••------.....--•--•-----.._...-•....
Nature of Repairs or Alterations —Answer when applicable ... 15Q0 --- gallon_ -tank__ With___2-1000...__.._____
gallonPits---------------------------------•------------------•---------...-----........----- ---
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLL 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has jrl issued by the bojr�j pf health.
Sigx>C 9 -18 -8 5...
D e
Application Approved By..-• ---- 7
D to
Application Disapproved for the following reasons: ..............................................................................................................
...................................................•-----.....----------------._...._._..-----------•---------•--....---••-•---•--••---•---•-•--...--------
Permit
f � Date
No._..._...._ "
0�f r�.
- 4 -- .... Issued . D J .._._....
ate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH .
.......................................... OF .....................................................................................
Tnr#ifirates of Tontpliitnrr
THISJS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by-----a�::1. ...........................................-----------------------------------------------------------------------
Installer
Ysions f TITLE 5 of The State Sanitary Code as described in the
has been installed in accordance with the pro
application for Disposal Works Construction Permit No....&S�./_ *�.............. dated ........................... ......................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.------ -`---ZAj•+_' •------• •------- Inspector ---•-- . .