HomeMy WebLinkAboutApp-Permit-Compliancee7 -1q7 / � .__ � s-�� O.�
No..------.•------ .. � �/9 S Fps. ....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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for 11iupouttl Works TonsUwtion jhrmi t
Application is hereby made for a Permit to Construct ( ) or Repair
( c,)-�ff_Individual Sewage Disposal
System at:
............ ` ..__. ..t4. r R- ::..... ...... .�... _........... ....... -...�' -�� �= r = .............................
Locaf Address
..---•-•-- -:.1. .(— .dL�L.I.iC :..-- 1F-r��-V.afSz (......._..-- 5.
or Lot No.
.1 ..... .......................................... __.....
Owner Address
..... lr It --i:�:9t. ...... � ------------------------�?%'-L---- Q.-Vk ... . �..�Q.........__.
Installer
Address
Type of Building
Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms ..... ��„7 3 .................................. Attic
( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures ........--•...............................................--------------------------------------------------...---------------
Design Flow .......... _____________________gallons per person per day. Total daily flow......`r�r� 5 ..--..............gallons.
Septic Tank -L Liquid capacity.10.37.tallons Length..... F .... Width... ........
Diameter ................ Depth ................
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ...... ............. Diameter ....... 1 :.- 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 ........................
Descriptionof Soil ............................................................................................................................
----....-•---------•-•--------•------•...........................................................•------------------------------------•-----•--------------.
•-----•----------------------------•--------------------------•---------•---•-----•----...----••--•----'-------------------------------•---------------------•-------...---......--------------.........
Nature of Repairs or Alterations — Answer when applicable..-z-zv,6'i.`y _4L.......L:n-zm- ... S'e"erf _-..`_ w-!
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1L 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has • �ued by the board of health.
Signed. \c --•--- iQ �-- ----
}ate
ApplicationApproved By------- - --- --•--- ............... ..................................................... .. n �' /
Da
Application Disapproved for the f oll ing reaso s: ................................................................................................................
.................................••-•--............----.....--•-----........••-------------------...............--------...---•-•--•------------
/ .ate
o� G� _
Permit No ......... >/ ........-1------------------------ Issued- .................. c - a ; ... l�•-•. f--
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-7.-....:....................:....OF.......We ..................................
Cnnrtgftratr of Toutplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by....................... ........1. y?clM6...:
Installer
at------------------_----`� --- (� :Y N�� 1--------------i'c' �f..�l iZ: t--------------.....---- ..............................
has been installed in accordance with the provisions of TITLE 5 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 CONSTRUE® AS A GUARANTEE THAT THE
SYSTEMA WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector