HomeMy WebLinkAboutApp-Permit-ComplianceNo..-:. Fins...rx�i..F.................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�'c GcJ
............ OF ..... .!!.�9.rze�4..
Appliratioo for Uispooal Works T000trortioo 1hrmit
Application is hereby made for a Permit to Construct ( � Repair ( ) an Individual Sewage Disposal
System at:
.-•--•---•^••-r------•.................................................. . . ..
_ Location - Address or Lot No.
...... i1 ......._....!'i.L( ....wner -•........................................................Gd-
........................
a -• .._... Address
----- J -----•-- ..--.._...•-----.----- ......
Installer Address
------------------------------------------------------------------------•----------------------....---•--------------------------------------------.....------------•---•----------.....................
Agreement:
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 agrees not to place the system in
operation until a Certificate of Compliance ha een is ued by the board of health.
Signed
Date
Application Approved By. ---- �`�-9J
- - - •----------- -----------------------------•-----------------•----------------------- - ---------.......---
Date
Application Disapproved for the f o lowing reasons: •---••------••--------•--•-•-•--------•---•-----------------•--•---••-•---------•-----------•---------------•.
....................•----••-•-••--•---........-••-----••----..........-•-------------------•-•-•---------.------------....---------------•--•-•-•---------•---•--•••-•---••------•-----•---•---------•--.
Date
PermitNo.... a:3 c�-..----•----------------------- Issued -...... --- - �----••---•--.-----•-•-------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......... ................................ O F....'......... ..................
Tntif iratr of Tomplinurr
THIS IS TO CERTIFY. That the Individual Sewage Dispysal System constructed ( or Repaired ( )
. �r
by - -- ----- °..... .' . . --- .. I/ = -• r -cc I
Installer ,
y^ ---------------------------------------------------------~,t r % - ••�__:?_" ........e r-✓.-------�� ' I -------------------------------------------
at ------- f .................. .�
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No: _',...___,:__/-----------------•- dated__,?___: ...1.___...____.___._.____._.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. �
DATE Inspector.- ..................•-•---------------
.. . ------------•---
Type of Building
Size Lot ... .`""Sq. feet
U
Dwelling —No. of Bedrooms............ �.........................Expansion Attic (
) Garbage Grinder ( )
'.P.,
Other — TyPe of Building No. of persons ............................ Showers Cafeteria ( )
Other fixtures --------------- --------------- --- -
W
Design Flow ............. ...................gallons per person per day. Total daily` flow ._._.....�..Z_®.............._.gallons.
WSeptic
Tank — Liquid' capacity 4 Qallons Length_.. A..---.. Width ...... Diameter________________ Depth_._ X__P -
x
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area..__................sq. ft.
�
Seepage Pit No._._..�.......... Diameter...../ ..... Depth below inlet ...... ........
Total leaching area -...&.!5 q. ft.
Z
'-'
Other Distribution box (4�� Dosing tank ( )
Q/9-,$ g*.
Date.... 1
Percolation Test Results Performed by.- z.ax.-sJ_--gr -e
............... ..........
aTest
Pit No. 1.... A. L _minutes per inch Depth of Test Pit__ l K'..
Depth to ground water..__.,.l 45 .......
Test Pit No. 2...4> -..minutes per inch Depth of Test Pit... .
Depth to ground water....EV,rt -_--.
P�
O
x
•-----•-•----••----••------••-•-•----••----••-------------•------•----••---•-••-----•----•---.--•-•----••.........................................................
= .. �.
Descri tion of Soil----�---�?_....---�-�-=-------.k�!•----�'--SSC_�....._�.Y._-_.1��------------------
-----------------
G---•-----=-��-&Z..... Sr;9-4. I---- ------ ...------
7----....
U
W---------------------------------------------------------------------------------•----------------•-----------------------------------------------------•--------------------•--------------------
UNature
of Repairs or Alterations — Answer when applicable...........................................................................................
------------------------------------------------------------------------•----------------------....---•--------------------------------------------.....------------•---•----------.....................
Agreement:
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 agrees not to place the system in
operation until a Certificate of Compliance ha een is ued by the board of health.
Signed
Date
Application Approved By. ---- �`�-9J
- - - •----------- -----------------------------•-----------------•----------------------- - ---------.......---
Date
Application Disapproved for the f o lowing reasons: •---••------••--------•--•-•-•--------•---•-----------------•--•---••-•---------•-----------•---------------•.
....................•----••-•-••--•---........-••-----••----..........-•-------------------•-•-•---------.------------....---------------•--•-•-•---------•---•--•••-•---••------•-----•---•---------•--.
Date
PermitNo.... a:3 c�-..----•----------------------- Issued -...... --- - �----••---•--.-----•-•-------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......... ................................ O F....'......... ..................
Tntif iratr of Tomplinurr
THIS IS TO CERTIFY. That the Individual Sewage Dispysal System constructed ( or Repaired ( )
. �r
by - -- ----- °..... .' . . --- .. I/ = -• r -cc I
Installer ,
y^ ---------------------------------------------------------~,t r % - ••�__:?_" ........e r-✓.-------�� ' I -------------------------------------------
at ------- f .................. .�
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No: _',...___,:__/-----------------•- dated__,?___: ...1.___...____.___._.____._.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. �
DATE Inspector.- ..................•-•---------------
.. . ------------•---