HomeMy WebLinkAboutApp-Permit-ComplianceNoA?'.: ! v,1.. Fps.
riffmfepteo THE COMMONWEALTH OF MASSACHUSETTS
S7-05 BOARD OF HEALTH
............ .................... OF ..... �
Other —Type of Building ............................ No. of persons __--_-------__--_____-- Showers ( ) — Cafeteria ( )
Otherfixtures.-------•---•---••------------------------------------•----------------------•--------------------•-------•--------------------------•--------------•-
Design Flow ...................... g P P P y Z� //O =?��--gallons.
��?.�............. gallons per person per da Total dail flew_______..._ ._.._____..____..__.._.__.
Septic Tank — Liquid capacity-/ 11ons Lengths. ' � _.. Width -_17j....'. Diameter____ __-__- Depth_ ��
> ., i Ir
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area --___---------_sq. ft.
Seepage Pit No ......... /......... Diameter..... Zo-__-_._. Depth below inlet_3'.4 ..7.._. Total leaching area l�_ _ .sq. ft.
Other Distribution box (�'/) Dosing tank ( )
Percolation Test Results Performed by___ 7 std_ - 5.� ___..__._.............. Date...... -----
,m
Test Pit No. *X ...............minutes per inch Depth of Test Pit ---- _._._...__ Depth to ground atet__ _-.:_ b `
Test Pit No. @ ................minutes per inch Depth of Test Pit.............._..._. Depth to ground water..__
- -----
......------------------------
----------
Description of Soil..............................-----.. --�--�-- S F��a
---------_------_--------_----------- '-/. _'....... -C.-'_H.... c__.__ ._
----•-------------•-----_.. -..-•------------------•-•-------------.
Nature of Repairs or Alterations — Answer when applicable .__________________..............................
------ -- •.-----------------•.----•-•--••----•-------------•----•-•-----------------......------------------------•---- ------....-------•-- /-.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in ac I Zndance wIt,
the provisions of TITTLE 5 of the State Sanitary Code — T undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee sue the boardof heal
Sined.. ........ N •---•--------------------------------------------
Application Approved By----- ---- --- ---- -- -............. • ���................
Date
Application Disapproved for the following reasons------------------------------------------------------------- 1=.... --------- ••-------------------------------
...........-•------•----•-•--•----••--------------------•----........----•----•-------.....-------------•--------------------•--------•--------•--• ......................................................
Permit Issued - `11�'
._._.._.
Datzlele
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
// f:..
Tntifiratr of Toutpliatnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (C,.)' o'` r Repaired ( )
by-------- • .Z:�fl.dl'Z .......... e_' ........................----------------..............................................
�! -- taller
at---•./ ---7 ----- ----- r1 _. t:.......7 .% ---- az ------ .✓ l ?__------- ----------------------------------- -------------------------
has been installed in accordance with the provisions of TITLE 5 o The State Sanitary Codas described in the
application for Disposal Works Construction Permit No ... ------ --------- dated ----- _ ........................
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® G NTEE THAT THE
SYSTEM FUNCTIOpSATISFACTORY.
DATE-Q-ll..D. - Inspect_::.. .
Appliration for Disposal Warks Toustrnrtiun 11trutit
Application is hereby made for a Permit to Construct
( or Repair
( ) an Individual Sewage Disposal
System at:
1-
•-
Locatio ess
- - --
or Lot No.
AJA
-
a
�� wner
-----•------ f111'�(r1.�111�. d T ---------------------------------- -------------------------------------------
Address
------------------ ----------------------------------
Installer
Type of Building
Address
Size Lot. .._.. .....-��....Sq. feet
Dwelling—No. of Bedrooms.................�_._.------_...._.....Expansion
Attic
(t- Garbage Grinder
Other —Type of Building ............................ No. of persons __--_-------__--_____-- Showers ( ) — Cafeteria ( )
Otherfixtures.-------•---•---••------------------------------------•----------------------•--------------------•-------•--------------------------•--------------•-
Design Flow ...................... g P P P y Z� //O =?��--gallons.
��?.�............. gallons per person per da Total dail flew_______..._ ._.._____..____..__.._.__.
Septic Tank — Liquid capacity-/ 11ons Lengths. ' � _.. Width -_17j....'. Diameter____ __-__- Depth_ ��
> ., i Ir
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area --___---------_sq. ft.
Seepage Pit No ......... /......... Diameter..... Zo-__-_._. Depth below inlet_3'.4 ..7.._. Total leaching area l�_ _ .sq. ft.
Other Distribution box (�'/) Dosing tank ( )
Percolation Test Results Performed by___ 7 std_ - 5.� ___..__._.............. Date...... -----
,m
Test Pit No. *X ...............minutes per inch Depth of Test Pit ---- _._._...__ Depth to ground atet__ _-.:_ b `
Test Pit No. @ ................minutes per inch Depth of Test Pit.............._..._. Depth to ground water..__
- -----
......------------------------
----------
Description of Soil..............................-----.. --�--�-- S F��a
---------_------_--------_----------- '-/. _'....... -C.-'_H.... c__.__ ._
----•-------------•-----_.. -..-•------------------•-•-------------.
Nature of Repairs or Alterations — Answer when applicable .__________________..............................
------ -- •.-----------------•.----•-•--••----•-------------•----•-•-----------------......------------------------•---- ------....-------•-- /-.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in ac I Zndance wIt,
the provisions of TITTLE 5 of the State Sanitary Code — T undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee sue the boardof heal
Sined.. ........ N •---•--------------------------------------------
Application Approved By----- ---- --- ---- -- -............. • ���................
Date
Application Disapproved for the following reasons------------------------------------------------------------- 1=.... --------- ••-------------------------------
...........-•------•----•-•--•----••--------------------•----........----•----•-------.....-------------•--------------------•--------•--------•--• ......................................................
Permit Issued - `11�'
._._.._.
Datzlele
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
// f:..
Tntifiratr of Toutpliatnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (C,.)' o'` r Repaired ( )
by-------- • .Z:�fl.dl'Z .......... e_' ........................----------------..............................................
�! -- taller
at---•./ ---7 ----- ----- r1 _. t:.......7 .% ---- az ------ .✓ l ?__------- ----------------------------------- -------------------------
has been installed in accordance with the provisions of TITLE 5 o The State Sanitary Codas described in the
application for Disposal Works Construction Permit No ... ------ --------- dated ----- _ ........................
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® G NTEE THAT THE
SYSTEM FUNCTIOpSATISFACTORY.
DATE-Q-ll..D. - Inspect_::.. .