HomeMy WebLinkAboutApp-Permit-ComplianceFicst t,
THE COMMONWEALTH OF MASSACHUSETTS
BOARD Of HEALTH
O�JI^...............OF....... '•J ...........•--•-•..........................
Appliratinn for Disposal Works Tonstrur#inn rami#
:Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
�S'T Qat: €»»:�.t�?�I..:_....»�!!�: �.�.t�rrrU` _......7-.»... 0.-------``' I o
Location • Address or Lot No.
.............• .»»--- `:::1.^. ta?.....------•--- ---------------».».»........
/! \ _ Owner Address
c............... .
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling — No. of Bedrooms ......-. �...........................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures-----•------------------------------------------------•----------------•------.-...-----.-..-....-----.-----.--------------..-------------------------
Design Flow ..................... .S..........._...gallons per person per day. Total daft flow ........ 3 P .......................
Septic Tank—Liquid ca.pacity.LQ°Q...gallons Length -.'-F!6`_`_---. Width -.VS ....... Diameter ................ Depth.S`........
Disposal Trench — No......I............. Width------ � <?........ Total Length ..---. �.'... Total leaching area ..... 323_---sq-ft. �
Seepage Pit No ..................... Diameter.................... Depth below inlet .................... Total leaching arm ................. sq. ft.
Other Distribution box (k) Dosing tank ()
Percolation Test Results Performed by.___-- �.c-_�u�st�!L�- ...................... Date.----.-- 7..-� a----------.
Test Pit No. 1... ! Z. .... minutes per inch Depth of Test Pit.. S e....... Depth to ground water.._5G.__-� .............
Test Pit No. 2................minutes per inch Depth of Test Pit.-..-.-.-----------. Depth to ground water ........................
........................•-- ........ - ---._.... - ..........._........
Description of Soil ................. ! � .... ` - ................
....--------•--------------•----------------.......----------.....------•--••---•----•--....------------........•-•• ••-•------
Nature 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 TITI.1 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee issued -by the board of health.
Application Approved B}c_.......... �`� ? ---- = ....
ate
Application Disapproved for the following rns:---•--------------------------------------------------•------...---------.•...-=------•---•-----•-------_.».»
..-•--•---•------------------------------------......------.......---..............-----•----•-. ...... ........................................................ ..................................... -
Permit No. -%71—#a �!L
--•---•----------------------------». D )-----
AA THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.l.h`...........
...................................
Trrnfirtdr of f90n41litturr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( )
by.. ............... -•--- ------------------ ...... ......._......._......------........ _._ .. ................--.»..»...._
�� ��: .�_IAtaller r.��_IE..)g' ...........................
--
has been installed in accordance with the provisions of T T]L,/�y5 of The State Sanitary C�de described in the
application for Disposal Works Construction Permit No. ........ ............. dated_OsQ/%______...__........._.._...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS NTEE THAT THE
SYSTEM „WILL FUNCTION SATISFACTORY.
DATW2' 7Z. 61 J� 2' . . .................. Inspector .r.� !- .. - `---...... -
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