HomeMy WebLinkAboutApp-Permit-ComplianceNo.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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............ oF..... .!R.w4a�.!-�.
Appl ration for Disposal Works Tonstrudiun Errant
Application is hereby made for a Permit to Construct ( ) or Repair ( Lan Individual Sewage Disposal
System at :
s3..... ...... .19tLtc. .' iQ ._.l.. TUC .............• -•--•---------•.........f •S&2..._.....� ...-----... -%
SLocation - Address or Lot No.
........ _....— ��.... l x�c.�ti..aa................................. .......--------- i --....---....------ -------------- ----------------------- .....--
Owner Address
.......G'4C_.................................... •------••-•--••--.f) C?�..'t - tt ..._..............
Installer Address
Type of Building ,�r Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms.... 7....................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures.------•----------------------------------------------.---•---------•----.............----------------...-•--------------•-•-•....•--•...._.....•----•
Design Flow _...._.'�--_:�..........................gallons per person per day. Total daily flow ------- 32.)_ ...................... gallons.
Septic Tank —f• Liquid capacity.l_ISM.gallons Length ---4.Q------- Width .... U......... Diameter ................ Depth ................
Disposal Trench — No. q..F- LU S.-- Width -.-.'R ............. Total Length.... §Q ........ 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 ........................
Descriptionof Soil ......................................................................................
------...--•-----------•..........................•-•----•--------------------------...............-----....---------•----------------.....----•----.....----•---------....•••--•-•-.......__._..._.....
Nature of Repairs or Alterations — Answer when applicable....- _►tiS ym%..... 1-su«.... S p _Vnk.IC.............
AL-----!ZA 06Z. ------.. -----------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIAL is 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 iealth.
Signe _ ---- ---•--................
i l� �.
Daty
ApplicationApproved By .... ... ... . .. ...................................................................... [/
Date
Application Disapproved for t e folio ing r asons----------------•----•--•---------...__.......-•-•-----------•.....-•------------•••----•--......•-•-....._...__
..
------........................................... a .........-•••-••---••ate .............
Permit No ...... . ........ Issued.- ��_ D' ! _� .l. M
-.. -...
ate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......��...... OF......�..Inla.Y�4.its..........................................
Trrtifiratr of Tomplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (liter
by...............
3 - ---._ Installer
at.................. _._..._ S,!a `` !� 12 l._c•9 *. — ---------------------------------------------------------------------------------------------------------
has been installed in accordance with the provisions of TITLE 5 The State Sanitary Code as d&scribed in the
application for Disposal Works Construction Permit No ------------------ dated ...... .....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....... AI.:.L>.= •-•---......-•------...--•---.. Inspector : t-1 .c ., J l ti f
.............�.......... 1