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Home My WebLink AboutApp-Permit-ComplianceNCFmc .............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ------- 7, ----- 1"10 F ......... . ................ Appliration for DI-wiial Wor Tomitrurtion ramit Application is hereby made for a Permit to Construct IV ) or Repair an Individual Sewage Disposal 2-I'system at*/)9/9P, a 5' ........................ - ------------------- ------------ .............. a lion Address or Lot NO. Ap............ .... X .. _�4&V ......... e .......... _2,4 .....Installer --- ------------------------------ Address Type of BuildingSize Lot ---f J_,O,� j. ... Sq. feet U Dwelling — No. of Bedrooms -------------- S3 ---- ........ . ........ Expansion Attic ( ) Garl4age Grinder ( ) No, of persons__..___. 4 --------------- Showers Cafeteria ( ) 44 Other — Type of Building P4Other fixtures -------_--- - (7 .......................................... ........................................................................... Design Flow .................... _ - 1-f gallons per person per day. Total daily flow --------------- 3-3.0 -------------- gallons. L Septic Tank —Liquid capacity/.gallons Length ------ ff !--- Width.-.,// ........ Diameter ................ Depth.._..._......... Disposal Trench — No - _---------_----- Width .................... Total Length ------------- Y_717 Total leaching area .................... sq. ft. Seepage Pit No.._.___.{._._.___.. Diameter ................ Depth below inlet_._.. ..... Total leaching area_t./3 --- sq. ft. 6 Other Distribution box (4-)- Dosing tank Percolation Test Results Performed by--... lltz, ---------- Date ... rV-1 //7 7 .......... Test Pit No. I.:!<.._-L-.-4ninutes per inch Depth o Test Pit .................... Depth to ground water ......................... Test Pit No. 2 ................minutes per inch Depth of Test Pit .................... Depth to ground water___.................___. ....... --- ................................... ....... ......................................................... .................................................................................................... 0 'Description of Soil----------- ... .. --- W -) - --------------- * ---------------------------------------------------- * ------------------------------------------------------- * --------------------------------------------------------------------- ............................................................................................................................................. .......................................................... U Nature of Repairs or Alterations — Answer when applicable ------------------------------------------------------------------------------------------------ ................................................................................ ....................................................................................................................... Agreement: 11 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 agrek , s not to place the system in operation until a Certificate of Compliance has been�ued by the board of 1*11th. ' D j --- ZF ........ _b, Application Approved By.. .... ....... 41;e C e Health Off cel Application Disapproved for the following reasons: ---------------------------------------------------------------------------------------------------------------- ................................................................... ................................. .......... .................................................................................. Date PermitNo --------------------------------------------------------- Issued ....................................... ............... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 11 . ............... ..................... OF ......... I / .... V. ". /......... Tntifirati of Toutpliattv TO CERTIFYThat. the Individual Sewage Disposal System con or Repaired THIS , constructed by --------------- ............tdnsta - ------------ ............. ... ................ -------------------------------------------- at ......... 4 has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as de cribed in the application for Disposal Works Construction Permit ------------- dated___ . ......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARA TEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................ L ...... ................. inspector ................................................... .........................