HomeMy WebLinkAboutApp-Permit-Compliancey. f
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THE COMMONWEALTH OF
MASSACHUSETTS
BOAR®Q HEALTH �12,��Z�
Av.p irttttnn for Btsvaaal Works Tomitrnr#iun Ilermit
Application is hereby made for a Permit to Construct ( DQ or Repair ( ) an Individual Sewage Disposal
System at:
./2 .................. ' ,.4
� row
^^ d - e ....
'�i1e ` 't'feAla fresp/_ orsLot No.�
--------------- K i! owner _ Address
--
------ ..-_-------
Installer Address
Type of Build' Size Lot ... 14/_1.Sq. feet
DwellingzNo. of Bedrooms ........ 7.�--------------Expansion Attic Garbage Grinder •F---j�
Other — Type of Building ---`_ ......_•..._..... No. of persons .................. Showers (—..) — Cafeteria
Otherfixtur..--------•- ...........................---------------------
Design Flow-•-• -• S 30
gallons per person per day. Total daily flow.....................................•..•.__gallons.
Septic Tank — Liquid' capacity/ lions Length___- -__- Width__. . ..... Diameter...-
iameter... ^".._._. Depth. ........
Disposal Trench — No. ...... ?"_`:...... Width .....1--------------
!!�.Total Length ..... _....._...... Total leaching area.....�=......... sq. ft.
Seepage Pit No ..... Diameter-__lle..._.___. Depth below inlet ..... ._._._._.. Total leaching area..�'%___sq. ft.
Other Distribution box X) Dosing tank
Percolation Test Results Performed by.._....110i'l� ���_/----A&i Date -------��I� �----G� -
Test Pit No. 1 �i ...__.minutes per inch Depth of Test Pit .................... Depth to ground water.._/ D
Test Pit No. 2. ._ - minutes per inch Depth of Test Pit ..__• ............... Depth to ground
•�? water__--.-___-----------___.
_ -w------t�------------------------------------------rt�y-------------•------------------------------------------
Description of Soil ....•..Q _ ..,(
------ - ----- - -- -- ---- ------------------------------------------------
f
•---•--••-•-----....-•-----------•-------•--•---•-----•••----------••----------••-----•-----•-••••------•--•-•---------------•---•----•--••------••-------••---------•----•----••••---•--•-----•--••--•-
Nature of Repairs or Alterations — Answer when applicable .__..-----'_.______-__•--______--•-•---------------------------------------------••-..-----.
-----------------------------------••----------------------•-----------------.-----....--------•------------------------------------------------------------------------------........................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
T
the provisions of �f'1Trl' --•
5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been is ied y the oard of health.
Ci crn nr� v
Application Approved
Application Disapproved for the
.........................................................
Permit No .......................
0
....................................
Date
Date
reasons:......................................................
................................ I --••--••-----------------•----•-----------------•-----••--------------•-•---• •----...
Date
------------- Issued .......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF ........................
�
rrtifiratr of Tlantplianrr
THIS IS TO CR�TI�/F•Y That the Individual Sewage Disposal S7stem constructed ) or Repaired ( )
by................ ✓-- ---------------------- --11....................... -------------------------------------------
Installer-_.,,
i
at Q/------�.............
.......
has been installed in accordance with the provisions of TITLE__ _. _. 5 of The State anitary Code s d cribed in the
application for Disposal Works Construction Permit No ---- _- 4 __.
dated_
' j---------------
THE ISSUANCE OF THIS CERTIFICATE SHAkf NOT BE CONSTRUED AS A NTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-------------------------------------------------------------------------------- Inspector---------------------------------