HomeMy WebLinkAboutOriginal T5 Application filed in 1984 - Not InstalledNo.. ............ «»...... F$sff
THE COMMONWEALTH OF MASSACHUSETTS _
BOARD OF HEALTH
_ TZti�J�........ 0 F...........................................................................
Appliration for Diopoottl Marks Tonstrurtion Permit
Application is hereby made for a Permit to Construct ( ) or Repair �< an Individual Sewage Disposal
System at
--� '......................»_.......----.----...._ «.. ........». ».
- ¢
LotAo......
�":.»« atioa: Address ?j
« »...........».......................................................................... .... ._......»...»
........ n� C� !/' G {� ` Address X.
......-•---•------------•........................---•-•---...............------...... ....--•---......-.---•--.........................._.....
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 ( )
Otherres.......................•---.......-----•---.................................-•-------......-----...------...--•----•-----------•---......
Design Flow....................................
......................gallons per person per day. Total dail flow................ gallons.
. •
Septic Tank — Liquid capacity.. .gallons Length..... t..... Width...... Diameter..-- Depth -..ST-`.......
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 ........................................
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 S
--------------•--•-------• . ---•-----•--------------•-••••-•---------•------•----.......--
l�j�ture of Repairs or Alterations = tAnswer when
lri - .fxS_.------- .
Agreement
The undersigned agrees to install the afored,
the provisions of TITLE 5 of the State Sanitary C
operation until a Certificate of Compliance has been
Application Approved
Application Disapproved for the f ollouring reasons:
PermitNo ........................................................
I/IndividuaAgnh
is osal System in accordance with
The undersir ees not to place the system in
by the oar
Date
---------------•----------•---••---•-•••— ........................................
Date
.---------------------------•-----------..........-----•----------------•-------..-•--•.
Date
Issued................- ................................
Dace
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALT
.......... /..i 'f;' ...........OF.....................................................
T ertif iratr of Tomplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal S7stem constructed ( ) or Repaired ( )
by--------------------------------------------------------------- --------------------------- .........
installer
at------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
has been installed in accordance with the provisions of TITLE j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ......................................... dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF...............'..................................................
No......................... Fim ........................
Disposal Works Tonstrurnan trrmit
Permissionis hereby granted .............................•--...-•---•----- --..............------•.............---................................--..............-•-•••--
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
atNo..................................................................................................... ........ ------•---------.......--•-----------•--•••------•-----•...-•----................
Street
as shown on the application for Disposal Works Construction Permit No ..................... Dated ..........................................
.. •--•-----•••..................•-•-............----•----•----.............._
Board of Health
DATE......................................................................
FORM 1255 HOBBS 6 WARREN. INC.. PUBLISHERS