HomeMy WebLinkAboutApp-Permit-ComplianceFinc..............................
No._
THE COMMONWEALTH OF MASSACHUSETTS
--------,.BOARD OF HEALTH
............ /-&12--�- --------------------------------------
........... OF ........
Appliration for Bhopo"Sal Works Toustrurtion Prrutit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at: g
............ _ ... . . ..... ....
MLocati l 0
................. ...............................................
... A
dress
r Lot No.
............ ,�Z.I�LLO ................ ..... ---------------
------ Owner Address
......................................... ..................................................................................................
...................
.... . ...............
Installer Address
Type of Building Size Lot ............... 3 ............ 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 fl
�a., ai. y w ............................................ gallons.
....... ..... i ................
Septic Tank — Liquid capacity ............ gallons Length ................ Widl Diameter.._____......... Deptl
Disposal Trench No. ------_--_------ Width .................... Total Length.................... otal 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. I ................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 Soil ---------------------------------------------------- -
...............................................................................................................................................................
............................. ............................................... ................ ....------
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Nature of Repairs or Alterations — Answer when applicable...,5;q ..... El- Ai_�_
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T I T TIZ 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Application Approved B
Application Disapproved for the j PfAker --------
V'16�
......................................
..................... ................
.... ..... ..........
Date -
,7
to
............
Date
PermitNo --------------------------------------------------------- Issued. -------------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOAR/ID I
DF HEALTH,
.............................OF.. .... ........
........... ......
Tatif irate of Tomplialta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed
by/_A� ......... z -r.............•----....--------------•------•--------------•---- ........................................... ..................... ....... I ---------------------------------------------
Installer
at_/"�� -- -------------------------------------
- ------- ----- _- - ------ - r.7111 -1:t;7 ------------
-3 he provisions of TI
s been
Mein accordance wit c
s b en install
application for Disposal Works Construction Permit No..!
THE ISSUANCE OF THIS CERTIFICATE SHAD
SYSTEM WILL FUNCTION SATISFACTORY.
or Repaired f
11-1,x
r TR r of The State Sanitary Cod as described in the
Oct
dated
/10-J`". 7 ................
iYF Ty
NOT BE CONSTRUED AS A =EE THAT THE
DATE-------------------------------------------------------------------------------- Inspector.