HomeMy WebLinkAboutApp-Permit-Compliance7_3017 .c�No...... Fics...... _..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD vOF HEALTH
Q .).................. OF .........
" .....
Appliration for Eltspooal Works Tonstrurtion 1rrnti#
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at:
...L k�..-------1`-Q. 'lA............... LOT –1J 2 2, M Aft -S 2
Location - Addressor Lob No.
.....Pal ..... ...Q.E-" CA a..Z..................................................
..................................................................................................
Owner Address
.......................... ---------------------------------------- .. ..... 7.2....ToSMAei....... $aca ..psi---------.----------------.--..-----------
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 ( )
Other fixtures _..._...
Design Flow............................................ga.11ons per person per day. Total daily flow .......................
..---_--.--..------gallons.
Septic Tank — Liquid capacity ............ gallons Length ................ Width ........ ........ Diameter ................ Depth ................
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ..................... Diameter .................... Depth below inlet-................... Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by ..................................................................... ---- Date ........................................
Test Pit No. 1 ................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 ........................
------------------------------------------•--------------------------.....-•----•---•-----•----•---•........................................................
Description of Soil..
-----------------------------------•------------•--------•-----------------------------------------------------------------------------*-----•------------------.....-•----•---•-------...-----••--•--.
Nature of Repairs or Alterations — Answer when applicable__..:r�I.S-'¢_C(-,rld.Z---- V_F.... A..._grzQ._. 6.4p............
...a tt4A.Alm)................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITL1: 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of iealth.
Signed.. .AJ�b----C-----1- •--•-------------- 5 � . I 11V7
Application Approved By ............ -- •............... ......•--.......--------•--•--•------•--.......--.•----.............. e
.�
.............................•-•-•------------Date
Application Disapproved for the f o owi reasons_ __________________________:.____.._._______._ _ ......._._.__
-------------------------------------------------------------- ----------- ----------------------------
ry _ � tc
Permit No. 7 f -------------- - - . Issu `f.[
Date......... ......
�F THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
../P.VVAJ...............:....... oF... yAgm.omrt...................................................
CInrtifiratr of Tontpliaurr
HIS ISJO CERTIFY That the Individual Sewage Disposal System constructedor Repaired
.
--•--•---.....---••......._.)................•---..... (�C)
Installer
�i'h!r.J[3Li�`N-_i�jc'4t?egT!--------------------------•-------••--------------------------.._......................---...-----._.......
has been installed in accordance with the provisions of T TLS r` of The State Sanitary C e y Sc ' the
application for Disposal Works Construction Permit 'o. �:_ c�.t..................... date ... -. - _. 6. f_ --- U...........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED ASA GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. `
DATE: �'............. %.:�`Inspect X`'2rt�'_.._� `� ..................................