HomeMy WebLinkAboutApp-Permit-ComplianceI5 �
No.gg..-l'1�......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
'a..................oF.........!y!2-t,(-......:`.....................--.--........................
Appliration for Disposal Works Tonstrurtion Errant
Application is hereby made for a Permit to Construct
S stem at
,1.1. - Oft.......... _......... ..
Lova 'oa. Address
.�.�.... e�+ '..................................
�? ...... ... . . ...!!t .....4. .......................................
Installer
( X) or Repair ( ) an Individual Sewage Disposal
AIP 12)
...
Wr
C
ess
- r-.-... ...-. •-................................................
Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms ................. 3. ...................... Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures-----------•-•-•-•------------------------------------ --------------------•--.-.---...._---------.--..--...-...-....-----.-----•---•--------------•--
Design Flow.........................................gallons per person per day. Total da' flow _.__........._._...._...._..._.___..._.....dons.
Septic Tank — Liquid capacity.l .ga.Hons Length...i-, 7.... Width...... 1�7,z. Diameter ....... Depth--------------
Disposal Trench — No ..................... Width..... ........... Total Length .................... Total leaching area ............------- sq. ft.
Seepage Pit No ...... �......... Diameter., .!..jam._..... Depth below inlet............,... Total leaching area..;?.. .6. q. 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 Repairs or Alterations — Answ,�r when applicable.kn.
Agreement:
The undersigned agrees to install the afor a abed Individual �
the provisions of TITLE 5 of the State Sanitary e — The unders- ec
operation until a Certificate of Compliance has issued by the b d
Application Approved By ........................
Application Disapproved for the f oll reasons:
6Q_Si�-1!�:.�-_1�3 �T
................... :1 .........................................
Disposal System in accordance with
her agrees not to place the system in
1k
Date
.................•--••--•-••----•-......-•-------.......-----.......--•---••.........._------................---•-----•----•---•-• d y ¢ - ......
Permit No..U.-1.4 3 ....... ...... _.._._....__._.._ Issu %lf.l (L ..__.... D ......
�' Date
f) cr
' °CJ"b(i t. i `-}� p D THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-7%�... }...t ................... 0 F............. �:.... ... �� 4.........................................
.......... ........ ...................
Trrfifiratr of Tontplittnrr
THIS IS O ERT Y, -That, the Individual Sewage Disposal System constructed ( ) or Repaired IN)
by.. tI..�t i Gr .-��lrtl :....................
ji°°° •� Installer
at.............................. .....,....................................
has been installed in accordance with the provisions of T F 5 of The State Sanitar.. ode dg 'bed in the
application for Disposal Works Construction Permit No ....... =:..... ................... dated.... .�.!'�.J. ................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS RANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..r---------------------•-•------•--------•-.----• ------------------------------------------------------------- Inspector ......................... • ` ,-••---• 7,V--•--•------•------............