HomeMy WebLinkAboutApp-Permit-ComplianceX-45
�..
....:..........
..a.� ..._.. Fss..` ..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
0.4VA(-
............ OF...... ---------------------------------------
, ppliratiou for Bispogal Works Tnn34rnrtion lbrmit
Application is hereby mad or a leermit to Construct (x) or Repair ( ) an Individual Sewage Disposal
System at: 4p ' ' /
-.-. ----
RR ��%% -.- o ation - Address A p 3 por Lot t `
Address
a
..............................1%----------FeA41,4....-----.•...------.......---....--------------------....----------...-----------------------...............----............
Installer Address ��++
P1
Type of Building Size Lot../14$ .... Sq. feet
aDwelling — No. of Bedrooms .............. ...........•_-_---•---___-___-Expansion Attic ( ) Garbage Grinder ( )
p, Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
P" Other fixtures-----•------------------------------------------------•-•-•-•••--•-----------••-•-•-•-------•----•••-•-••---•----•••................................
Design Flow -•---.-••••_•••-_--_•••-•-.:_.<�� __gallons per person per day. Total daily flow.................•......3 _ d -_-_-_gallon
W Septic Tank — Liquid capacity/Qd(1 gallons Length �__-`�i._:
•••. Widthl_/Q ___ Diameter ---------------- Depth_4._."¢•_-
Disposal Trench — No . .................... Width .................... Total Length .......... __ Total leaching area .................... sq. ft.
Seepage Pit No ------- (------------ Diameter.G f_4 ._!__ Depth below inlet-- � ............ Total leaching area._ -Z.0_4_ --.sq. ft.
Z Other Distribution box ( x) Dosing tank ( )
'-' Percolation Test Results Performed by .... ---I&IRMLrJ.... Date.....A _Zap .
X r-J2_m.-----_.
Test Pit No. linutes per inch Depth of Test Pit 4'1.._ Depth to ground water-____�_/.7,�...-_.
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
•...-••-------------------•• •--••-•-••-••--•--••---•-.--•--•••--•-•-...........•----.......---...-•--•------•------•...•----•...--•-•-•------•-•••••.
O Description of Soil _._-_U.-1 A)..___--0-l_.0.�'J-9-------rb_.... FIME__-_66! 0._...uivaa .---.X.,r 1, ...-----
x
W ----01 -'
UNature of Repairs or Alterations — Answer when applicable .•-------------------•_-_______________________-________-_•--•_----_--__-__--__-_---._----___.-.
-•--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------• •--
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
therovisions of TITLE, .
p of the State Sanitary Code —The undersig ed further agrees not to place the system in
operation until a Certificate of Compliance has Zbeen' ue t ar, of- health.
Signed. • •....------••---••--•••••---- 6S79---------
Date
Application Approved By......- 7�
Date
Application Disapproved for the following reasons: ---•------------------------------•-----------------------------------•--------------------• ------------------
---•-•-•••-....-•••----•-----...--••-•• ------........................................ -........................ ............................. --------------------------------------------•---•---
Date
PermitNo......................................................... Issued_ .......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............. I............................ OF .....................................................................................
dw
up rrtifiratr of T.untptinttrr
THIS 1,5VTO CERIT Y, That the Individual Sewage Disposal System constructed (XJ or Repaired ( )
by.
.LL ........................ ..-••------ _�........... _i*_ _.e-_ _________.-•..-F-=.ww.-----------------------------------------------------------
I
_•--_ -__ _•-••----__ _ __ _ --••_ __
has been installed in accordance with the provisi ns of TITLE j of The State Sanitary Code as descried ed in the
application for Disposal Works Construction Permit No. -- ._.___ ....... dated -------- _. ._... �6----•-•--
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GU ANT E T6fAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector.