HomeMy WebLinkAboutApp-Permit-ComplianceNo. ...................... Fps....... _..... _ ... .
THE COMMONWEALTH OF MASSACHUSETTS h
BOARD OF HEALTH
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..................... OF ........ X 1�`CNQ QX0.--------------------------.........------•---- u
Appl ration for Disposal Works Tontrixrtion Vvermi#
Application is hereby made for a Permit to Construct ( ) or Repair (X an Individual Sewage Disposal
System at:
...�...T.a '�?.. �:�-. v ..................................... .............1 ..`':i3----- -t')') P -..`..........................----
Location - Address ---- or• Lot No.
-- j�. 114=.__........S� Q.. S�.sly..-----•----------------------------•----- - �".. `=......-•-------•----- .......................... -----•--•-•------.•.............. ---.....
.Owner Address
(250-_-_ �;sg!C,...--•...............•.............. 22� ...... C-JTU—vwk
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 ( )
Otherfixtures-----------------_-------.................------..................------------------....-----------...---.......---.........-•---------•-•._........
Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid' ca.pacity..__......._gallons Length ................ Width ................ Diameter ................ Depth ................
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 ........................
Descriptionof Soil --------------------------------------------------------------------
........................................................................................................................................................................................................
Nature of Repairs or Alterations —Answer when applicable�!Nn_± .fNiA..... ....... �D
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-........E?ra.i' ` �Vb ---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 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.
Signe`_.\"}^�-----------------------•------------. ------ )d. � ------
Dat
Application Approved By .......... ......... .................................... -------- a _l_
Da e
Application Disapproved for the following reasons-------------------•-------------------------......•-------------••--------------------....--------••--....._
\ Permit No ...... g o --- 7 Cc�--••................. Issued- V--- -- .....-?�Date
�A'lq 0
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�R
.....:.C?t.a.? ....................OF.... f ... . ... Y!10 J T-.`. .................................................
Tntifiratr of T -am rlinurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (14
by...... }icc_t`!=`f...C'+?w�,�...... ...--•--•••-------••-•----------•.....................•----•-•-•---•---•-•---•-------•••----------•------•-•--------------.....
Installer
.::' tm...........-.`<h ve r� o_ �--k .................................................................................................
has been installed in accordance with the provisions of TITLE 5 of T State Sanitary Code as described in the
application for Disposal Works Construction Permit No.....--- 0_-.�-.Z1�._..__. dated ...... 2-_/3 .........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A GUARANTEE THAT THE
SYSTEM �V'" FUNCTION SATISFACTORY.
DATE.... +�..- •4- 3- ..._ Inspector..:.....----------...----•-•----...---•--...........-----...............•.......