HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
-_---------_ OF ...... A�Z�....................... .
Appltration for Disposal Works Tonstrurttun rantit
Application is hereby made for a Permit to Construct ( V�0_r Repair ( ) an Individual Sewage Disposal
,System at
.... � ! . f., rte ---------------------------
ion ress
✓1?... ... .l
ow
............................ I...... .
Installer
Type of Building
Dwelling — No. of Bedrooms...........
.............. LO
or Lot N _
Add
................................
Address �
Size Lot/>__.t__ i;�3Sq. feet
..Expansion Attic ( ) Garbage Grinder fV 0
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures --------------- _------ ----------•---•----•---- ------•--•-------•...-----------------------------•--.....--------
Design Flow ................. �1.j6............... gallons pe �er ay. Total daily flow .................. �!2.............. gallons,
Septic Tank —Liquid capacity.f620gallons Length .____ Width... �1 Diameter ................ Depth.=97 .Y_.
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .......... _--------- sq. ft.
Seepage Pit No ......... /'.......... Diameter........./ _. Depth below inlet .._.._---------- Total leaching area ..ZA_)�... sq. ft.
Other Distribution box (L.,� Dosing tank
Percolation Test Results Performed b ___...1 :_°>__��`_..��._. Date... _._ f
Y -------
Test
-PI-
Test Pit No. 1 _ �-'_Z'_:minutes per inch Depth of Test Pit../..TZ ---- Depth to ground water --___f__
Test Pit No. 2__ G.. �-.minutes per inch Depth of Test Pit../'.3-.Z....... Depth to ground water ------ _
---------•--------------•---------------------•-••..................-•--------•-----------••--------•---......-•----••--•---.............--•---.
Description of Soil.-
40-= - ® - _Z:;ice 2 So �C �- ef?�
..t �...... ....�-
Q- .... _.q .f4? � .. ..........................
-------------------------------------------.......................... ----------•----••---•-•---------•----•---••----------••-------•--------------•-•-•--•-----•---................................
Nature of Repairs or Alterations — Answer when applicable..............................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Ixlaividual Sewage Disposil System in accordance with
the provisions of TIT1E 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issue A�'y the and of health.
. Sign = `�------. �r�`'.C��._..
Application Approved By ... .................... .... ....................... �` .�7- Y ---
� Date
Application Disapproved for the following reasons:.
...................................................... I.-•------------•--------------------•--------••---•--•-----------------•----------...--•-• /---------------------------•-----
Permit No ...... I....`-��-.- ------------------- Issued-- ... r-----( J -
Date /
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............ ................. OF ......... ...........................................
Trrfgfirab of Toutpltttnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (7-br Repaired ( }
by--- _ -- l = " - =�� ... . -----•-------••---••--•-----------------•---••......---•-•--•---•--......
A Ins�Aller r!
at-------------- 7........... ..-----{-----••--•--. -------- - -- -- ` --t---- ................................................. ---- ---------------------
has been installed in accordance with the provisions of TITIE 5 of T, Code
/as Sanitary Cods described in the
application for Disposal Works Construction Permit No .................�'_.........._. dated --------- _! j'"_�`.----.......................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.. • . = Inspector ......................... ....................................................