HomeMy WebLinkAboutApp-Permit-Compliance6C9
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THE COMMONWEALTH OF MASSACHUSETTS
/ BOARD OF HEALTH
/...........0F............_--------------------------
Appliratiou for Uiipotial Workii Ctotaiitrurtiou Vamit
Application is hereby made for a Permit to Construct (,X) or Repair ( ) an Individual Sewage Disposal
Syst _ at
................ . --.. .... ..-- ....
Location - Address or Lot No.
.......... ....... ..... __ ..... Address
Owne�r��))��,,��
Al�3e �T V G-�._Q------------------------------------------- ...--...------------.
--------------•--'•---• •-- ....._......_....----• Address
Installer
Type of Building Size Lot.Z7_1-------------- Sq. feet
Dwelling — No. of Bedrooms ------------ -------------•---•._._.._- Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building _..--_._•------------------ No. of persons -_----_•-•-..------•------_- Showers ( ) — Cafeteria ( )
Other fixtures ---------------------------------
-r --..-------•-------------------------------------- •--------- -------------------------------
Design Flow ....... perms -per day. Total daily flow______________________3_��__._........galons.
Septic Tank — Liquid' capacity,/aa0gallons Lengthy ----- Width.=lG... Diameter ................ Depth..-;-..
74
Disposal Trench — No. -------•-•------••-- Width .................... Total Length ...__.•-----._.---•- Total leaching area .................... sq. ft.
Seepage Pit No ..... 1............ Diameter.A�__./57— Depth below inlet--- Total leaching area --- 0.6.x --sq. ft.
Other Distribution box (JC) Dosinank (
�'G // _.. Date....OO - ��
Percolation Test Results Performed by.._....o'.._ / . !6. V/- l .........1
Test Pit No. 1.. . _..minutes per inch Depth of Test Depth to ground water ....... __________........
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
•-------•----------------------------- ---------------------•--------------
Description of Soil ----Q Z��---------- ./S?PsOI P 'r �-------• -----•----------•--------•----------•--------------------
- -------------------------- -------
.....
Nature of Repairs or Alterations — Answer when applicable...............................................................................................
i----------------------------------------------------
Agreement:
-----------------•----------- ------Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITI:. 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee s u b d t rd health.
,_ I�-" D.
Application Approved By
Application Disapproved f
------------------------------- .D- -t ..... ---------
•---•-----•-••----.........................................................-Date
Issued--------------- .......
PermitNo----- .Ll-. --•-•-•-----------•-----------•------•--- e
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... O F .....................................................................................
Tntif iratr of Toutplitturr
THIS IS TO CERTIFY, That the dividual e Disposal System constructed (,(�j" or Repaired ( )
by ------------------------------------------------------------------
g........................_;, ----------.....PT ..........
(......................................
at------------------------------------------------------------------------------------- ----!�-C/------ ------• --•--•--•-•----------------•----------------------------
has been installed in accordance with the provisions of TIT r. 5 of The State Sanitary Code abed >>the
application for Disposal Works Construction Permit No.___. !-_� _---__----.- dated ----- _ 1-......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BEC STRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
f /-----•-----....-•--••-•------••---------•--- Inspector.-- . . Gi
DATE ................. - - •----=----•------.._...-.........................