HomeMy WebLinkAboutApp-Permit-ComplianceNo. B7___V1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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01
.................................. •--......OF...L �................_..---.......--•--•--....--•--.....---.........
Appliration for Dispooal Works TonsVamit
Application is hereby made for a Permit to Construct ( ) or Repair (Cl<an Individual Sewage Disposal
System at •
Location - Addres
... -- -{ .... v'•'"- — ------ caner ..........................................
Installer
Type of Building
Dwelling —No. of Bed
Other — Type of Build
Other fixtures
Design Flow------------------------- -------- ------ a
Septic Tank — Liquid ca, acity._ ........ga
Disposal Trench — No ................... Widl
Seepage Pit No .................... D' meter.....
Other Distribution box ( ) I
r- Lot No:
dress
-----------------------------------------------
Address
Size Lot ............................ Sq. feet
..Expansion Attic ( ) Garbage Grinder ( )
No. of persons ............................ Showers ( ) — Cafeteria ( )
....................................--•-•--•-----------•--------------------------------------------...---•--------------.
per person per day. Total daily flow............................................gallons.
Length ................ Width ................ Diameter ................ Depth----------......
............... Total Length .................... Total leaching area .................... sq. ft.
....... Depth below inlet .................... Total leaching area .................. sq. ft.
V tank ( )
Percolation Test Resul s erformedby -)Depth
-----------------------------------------•-------------------------- Date ........................................
Test Pit No. 1........... _minutes per inch Depth of Test Pit .................... Depth to ground water........................
Test Pit No. 2................minutes per inch of Test Pit .................... Depth to ground water ........................
-----------------------------------------------------------------------------------------------••.----....•--••-•-------•--•------...----•-•-••....•--••-....
Description of Soil..
---••---•------•-------•-•---••-•--••---•-••--•--•--•-------•-•----•--•-•-----••..............•------------•-----------------------------. --.......
Nature of Re a' or Alteratio�ns.�swer when appGicable.__ _ _. .._ _ �'z ..e- --.- .d f
-------------- --- ............
.. `._.�_ �. ' ..... -•-- -�� �L�S�.........................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL - 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 boa ;d of health.
Sig/�d ....... .............. z,;L - Z 2-g
ate
ApplicationApproved By--- . _,i' ... ------------------------------------------------------------------ -•----
Date
Application Disapproved for
V
the f o owing reasons...............................................................................................................
_
D to
PermitNo................... ......---•------------------------ IssuedJ _--------------------1! .�------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF...... -���!.�J...�............................
hia ifirtth" of Tontplittnrr
THIS IS TO CERT
Disposal System constructed
) or Repaired (
at................... ------------•-• _ ��' � ..C:... .tea -------.-- 0...... -----° j�--------------------------------.-.----------
has been installed in accdrdance with the provisions of T�Tn F' 1 ` of The State Sanitary de as es
application for Disposal Works Construction Permit No...�_!__` "7_. �.�------------------ dated -. ?�......... ..* .. ....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A ,GOARANIIEE THAT THE
SYSTEM ILL FUNCTION SATISFACTORY.
DAT ......:---•------- �=-•---•----•�---. J ................ - Inspector_�------`--`-�--------' -----'"-ZJ .=--2 :-��
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