HomeMy WebLinkAboutApp-Permit-ComplianceN,.-2 5 _.18 3
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF �`/J2�C01yI1
Fim.......j ..—
Appliratinn for Ui ipwial Wnr1w Tomitrnrtiinn Frrmit
Application is hereby made for a Permit to Construct
System at:
Location - : ddress
...........� C��!5..............................................................
owner
j4-/li c b
or Repair (L-�aan Individual Sewage Disposal
or Lot No.
..................................................
Address
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling—No. of Bedrooms ------------ ------------------------------Expansion Attic ( ) Garbage Grinder ,�e s
Other — Type of Building ............................ No. of persons ....................... .---- Showers ( ) — Cafeteria ( )
Otherfixtures--------------------------------------------------------------------------------------
Design Flow............................................gallons per person per day. Total daily flow... ......................................... gallons.
Septic Tank — Liquid capacity.. ---.......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. 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........................
Descriptionof Soil ........................................................................................................................................................................
............................................................................................ ---------------------------------- ---------------------....------------------------------------------......
Nature of epairs or Alterations — 4nswer when applicable.... Ig o............. �d...............+�. d. ._.....l
Agreement: 17
The undersigned agrees to install the aforedescribed Individual Sewage Disposalk'System in accordance with
the provisions of TITLE 5 of the State Environmental Code — The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued b the board of health.
Signed .. - c - �,��-
g..................... . . .............
Application Approved BY----�'...............................e
Application Disapproved for the following reasons: ............... ... ......------......---.....-------------...........................-----..................
......................................... .,_.............................................................................................................................................. .............................
_ Dace
Permit No. R S l �� --� .�
.................................................................... Issued .---------...--
Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF
C�eztifi� ate of C�nm}�Yittlnce
THIS IS TO CERTIf Y, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ---r
.4itJC
,�•. ,° laccallcr
at.............................x.`:-r/-�---..............--.... :--• G� 1,
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. C(--...1 �-I, `-P ..................... dated�.-.q.S.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION
SATISFACTORY.
DATE
DATE ..... ....../TI.�� ............
............--... Inspector.....
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