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Home My WebLink AboutApp-Permit-ComplianceN6FER l0 �.FP-T(Fy No. JI: A THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - rW.,—..-•--.....OF................. jq' H.0 Appliration for Disposal Murks Tanstrurtinn 1hrmi# Application is hereby made for a Permit to Construct (XI or Repair ( ) an Individual Sewage Disposal System at: ............... ..................... e.416 ------_ cation - dress or Lot No. . � .....% c __..i� : t - •------------------------------------------------------------------------------------------ ---------------------- %� Address . .......................................... ............ --................................... -................................................ Installer Address , Type of Building Size Lot-._�5'C Q ...... Sq. feet aDwelling —No. of Bedrooms--------------- ....._........__.._.....Expansion Attic ( ) Garbage Grinder aOther — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( ) d Other fixtures ------------------ W Design Flow.---.....� ........................gallons per person per day. Total daily flow ............. ©............... olons. WSeptic Tank — Liquid' capacltyS_-S=QL?..gallons IFength_.. _. .._ Width -._s.. .._. Diameter________________ Depth__ ..... x Disposal Trench — No. ------- 1............ Width ..... !Z�:......... Total Length ..._. Z- e .._. Total leaching area. -a-27, ::Z:_ sgr•ft: 6; top Seepage Pit No ...................... Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft. Z Other Distribution box Dosing tank ( ) Percolation Test Results Performed by..... .-- ? ____:...: � ►, r . �......-.._.. Date ....... 7- f d-:-� ._... Test Pit �'�o. 1 ...... .------_minutes per inch Depth of Test Pit .. � zr._.__..._ Depth to ground water.._. LSU.-----.__. L>~ Test Pit No. 2................minutes per inch Depth of Test Pit-__--._.-----_-_---- Depth to ground water ........................ ...................... ........................................................... C;k O Description of Soil. .....•-•-�•-•--...--•-•---•------•---••-----•-----•--------•---•----•--•-••••---•--•--•-•-•-•••---•------•-----------------------•- W w U Nature of Repairs or Alterations — Answer when applicable............................................................................................... --••----•----•--------------•---------•------------------•-•-----...------------------------------•---------------------------------------•------------•------------------------------....-------------- Agreement : The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT:.1� 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 o�f/he4lth. Sig .d.._... v_`�T�-------------- !. Application Approved BY-.- = Date Application Disapproved for the following reasons---------------••-----------•----•------------------....--------•------------•--•-----....-----•.....------------ ........----•-•....................•..........-----------...-•-•--------....---------------•---------•---I ......................................... ------------------------------ •-•-•--- •----.-•--- Permit No .... ��---...�/ �//c ........................ Issued--- • :...4 . �...... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............. O ', i !% ? .'?�1� ............................................ Trriif iratr of Tomplinure THIS IS TO CERT, FY, That the Individual Sewage Disposal System constructed ( d) or by---...r P . ..........f,.1! ...s' .................. �� _ > ,Inst lof has been installed in accordance with the provisions of TIT r 5r) of The State application for Disposal Works Construction Permit No._.._-��`___.;r �U .-•--_-.---- I THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE SYSTEl -)WILL NUNCTION SATISFACTORY. �-- the,