HomeMy WebLinkAboutApp-Permit-ComplianceFJ
NO..-... FES �v_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appliration for Uispuiitt1 Warks Tonstrnrtion thrmit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at
�. vT"&-! (o Is
L/ .Location - ddres
Owner
................••...---------•----••-•-•-
nstaller
Type of Building
Dwelling — No. of Bedrooms ..............
-•--•-----.....------------•-------------•---•.
or It No.
------------------------
- Address®
Address
Size Lot..L>......_Z-o------ Sq. feet
.............Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons .......... _................. Showers ( ) — Cafeteria ( )
Otherfixtures------------------------------------.....................................
Design Flow ......................... �J-_ . ....... gallons per person per day. Total daily flow .................... 3a.n............ •gallons.
Septic T2/ZwZc�-I�
I-iquid capacity,/DOUgaRons Length.a. `'_ Width.g(_ 6?' Diameter________________ Depth -.S' L�'
Disposal — No. ----- ........... Width .... 62.1........ Total Length..,'—'Z '_...._.__. Total leaching area___2 8 `1 -----sq. ft.
Seepage Pit No ----------------- Diameter ............ _....... Depth below inlet .................... Total leaching area .................. Sq. ft.
Other Distribution box (X) Dosing tank ( ) /
Percolation Test Results Performed by. E �S'�........................................ Date.31.�...........................
Test Pit No. le�F l3n--minutes per inch Depth of Test Pit. .LD? `....... Depth to ground water_I1&A��
Test Pit No. 2/f-rgz.minutesper inch Depth of Test Pit___ `...... Depth to ground water ....gF_`-_-...____
Descri tion of Soil..... � 4!4. �1 ^1� c�' °�l' U � OA 3 `' G 0 A7 �'�b
.................----------------------------------------------•--------------•-----•-----------
c�t?J'v f 4-
..----•-.......................--------•-....••------•-•-----------•----•------------...--••-•--•------•----•-•---....--•----------------•--------•---•-----------------•-
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 TITLE 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 health.
Signe ---- 7 - d`-. '_Q fo
----•----
Application Approved B.c%. -1- -• %9K
D
Application Disapproved for the following re S:............................................................... .:........ .....................................
...................................................................................................................................... ---•-...................................................
QQ —/Date
Permit No.-_- K.�--------•----------------------- Issued- --------------- - y / `---
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 'OF HEALTH
4
?� .....................OF....... e'r1FG Ifl....................................................
Trdifirate of Tomplianrr
WS IST CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by---- --•-- -••----••--. -•--•- •- -- -------------------------------------------------------------------------------------------•---
%„ ,,T_ J fy c� Installer
at----'-•---------------
......... ......... .f --_-_--- ------.--- _ ----__ _-------•------.-.-...-..-_-.--._---..-.-__------ .�" -----. i' * been installed in accordance with the provisions of Ti �.� A. The State Sanitary �o�, described in the
application for Disposal Works Construction Permit No. .._..... 2` 1 .................... dated__ _w_ _ ..........................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A ARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. C
DATE.�ZtX-.j 1`IS7
f..................•---•-•----•...---------- Inspect f