HomeMy WebLinkAboutApp-Permit-Complianced
U
a
a
a
w
W
Z
W
14
w
14
x
W
x
U
n V),CA 3�(�—SULGi� �� c� 1�I�P-e
J �d
No.....cl-_ ,"�13 FEB....... .
/Or
THE COMMONWEALTH OF MA TS ?f � 1 `�� C�.� �'f✓ � �' l�� �1 �_
BOARD OF HEALTH s
®w>1% pFy /�c�l�
F........
Appliratiou for Disposal 10orks Toostrort . krum
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at:
. 1-- -�T �
- 7 ------------------------------------------------------------------------------------------------
------------ ------------------------------------
------------_--------------- , .
Location - Address or Lot No.
.........•••-••-••.... . ................................ ..._.....--••---••-•••-•-••...._......_.......---------...__...•---_.................................
O.pw..................•---•.--••••••Address
Installer Address
Type of Building Size Lot_-� �VV ....Sq. feet
Dwelling —No. of Bedrooms ............................................ Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures•---•-•---•----------------------•------------•-------.-••--------•-•-----••-----•-•-•-•---------•--•-••------••--•--•-•----•--...................----
Design Flow..........................................gallons per person per day. Total daily flow.............................................gallons.
Septic Tank — Liquid capacityl.gallons Length__4!_Width"?�Zq� _. Diameter ................ Depth -4 -.....ii
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area ..................... sq. ft.
Seepage Pit No ......... r......... Diameter._... . Depth below inlet .... -err._. Total leaching area..4A7.---sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed b �d�y✓ _ ______ —C•R....... ate._ _. l
Y �' �� r .....
..............
Pit No. l.L +p.minutes per inch Depth of Test >t..._ r'�...__ Depth to ground water ........................
Test Pit No. 2................minutes per inch Depth of Test Pit.__Z ,...... Depth to ground water ........................
....................... ............ ---,--�c-�---------------------------------------------------„------------------------------ --- -----------------------
Description of Soil- O = WoOD �gT7.. ..5�'ru 3 - .Soi — 7Z � .wP S
r r VL-=?y..�._. rf...ae �j /” /!'l •,,�• �U----------------
. s=4?vv._.....:.. �� ---- - .... �`rN 6 sA ..............................................
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 TIT I,;,�. 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.
Signed------------------------•-----•-------•------------------------............•....._. ............. -------•---•-•--
ApplicationApproved By ..... - ....... -- - . ..............•--•------•-----------•-----------•-------------------�-Ol`-' -- ........
ate
ate
Application Disapproved for the f ollowi g reaso :••-----•-----•---•-----••-----••----------•-----......••.--•-----------•---•---•----•--•---- ------------------
•-------------------•------•-------•-•-•......__.....------..............-•----.......-----------•--.....-----------•---•-•--------•---•---•-•------•--•------•---•-----•------••---••--•-•-•--••••-----
Date
PermitNo---- 3�--------------------•---.--. Issued - ---------f ...................
Da
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
'k� .!!!r...oF....�9 r�ae ►c. ' ..................................
(irdifira#r of Tompliaure
THIS IS TO CERTIFY, That the Individ al w, e Disposal System constructed (�cj or Repaired ( )
bY........................................................................ ,1.----� _ ..--•-----•-•--------- ------......---•------------•--•---------•--
at................... -------•----•-•-------------------------------•---------- I to ` - ------N"" ...............................................
has been installed in accordance with the provisions of TIT F r of The State Sanitary CqAe described in the
application for Disposal Works Construction Permit No.... -------------- dated.__.f� , '1...._............_...._.___..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA ANTEE THAT THE
SYSTEM WILL FUNCTION S T FACTORY. -
r�
..... ,z . ---------------------------------
DATEInspector---- ..! .. ................