HomeMy WebLinkAboutApp-Permit-Compliancef ' f �f/ 1
No. C.1. -!.f Fims...'7TD ®......... .
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® QF HEALTH
....... OF......_.7x----------•---••-----••••••-----•••---•-- ..
Appliratiou for Disposal Works C>z. mitrurtion frrmit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
S47e
en at,,,/G//: /K1. .....�� .. .. a................. .� �........................... ....
Location - A s .v— .o�,�,�t No.
........... ..V7? . .art,.. ...... 1/�G. . � - ......:
�6 Owner. �`.].._.......Addrrgs
Installer Address Q
Type of Building Size Lot.._%Sq. feet
Dwelling —No. of Bedrooms ...........�------------------------Expansion Attic ( ) Garbage Grinder �O
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtu e .......................... -------------•---•-•••--........-----•---------•----•--------------•.......................................................
Design Flow ............. 7� .___gallons per person pe/ day. Total da y flow__...___`���_��_ _--..............gallo s,�
Septic Tank — Liquid capacity . .,gallons Length_��----- Width. ,l _... Diameter.... -..... Depth..��
Disposal Trench — No- -------------------- Width ...... �__.__.__._._ Total Length -.--__---------- --- Total leaching area . ...... sq. ft.
Seepage Pit No ......... /........ Diameter .... /.�.._..... Depth below inlet__ .mac .... Total leaching area. L5 �...�..sq. ft.
Other Distribution box ( ) Dosing tank ( /.� -� •�
Percolation Test Results Performed b ...... _ _P.16 �27 r/ e ------------ Date--- - /✓�__ __.
Test Pit No. 1.... :!!� Z minutes per inch Depth of Test Pit .... ��...7... Depth to ground water _________________-------
Test Pit No. 2...__. minutes per inch Depth o€ Tem -Pit... &. ..... Depth to ro ater........................
Description of
---------------------- --------------------------
Nature of Repairs or Altera
.............................. ......... r..... r— Gam .......................
— Answer when applicable. ..........................................
--------------------------------------------------------------- ---------------------------------------------------------
Agreement :
The undersigned agrees to install the aforedescribed Individual
the provisions of TITLE 5 of the State Sanitaid
The undersi3
operatu 1 a erti to of Compliance ha bee�heSigned.'.-- --
Application Approved
Application Disapproved for the followinf reaso4s :..........................
........................................................... .............................................
PermitNo.-•----------------------------------------
vage Disposal System in accordance with
further agrees not to place the system in
health.
-- - .--�'=�-
.7
Date
Issued. -------- -• --....-.% -
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
lOF.:...y1:4.n;l..............
Trrtifiratr of Toutplinurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (�or Re aired:, )
c -
by ................. e°�a:� - ----------------........----......--P-•-------•------•-.
Install j�
at.---•- -------- .
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 ---- _;5�:........................... dated ___._-_-•_.___.-..•.---____._--•---------.--•--:
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A NTEE THAT THE
SYSTE FU/NGCTION SATISFACTORY.
DATE -----�-- 1 c�
-•---••---•-... ,� `C .................... Inspect................•...��..... --- -- ........
----- •--•---------••-----------•-