HomeMy WebLinkAboutApp-Permit-ComplianceNo..�d:�a) FEs.......i. ............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
C_..O.W.Y*................. OF .......
y o,a .
.......................................
.....
for Uiipnsal Works Towiirurtiun ramit
Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal
System at:
- -....:7...T__ s.0.-�._. 5,.:xslu-------------------LQT - W- Yr, P.:.¢. .---------
•- -
(� ion - Add ess or Lot No.
(i L
TS. Y� CL. _.. 7.:Qr_......... L ............
nn / \ Owner Address
S Q mc .........
:.__ �LY�21ts �_..
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms ________-3 ............................... 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 capacity_lboo__gallons Length ................ Width ................ Diameter ................ Depth ................
Disposal Trench — No_ ____________________ Width .................... Total Length .................... 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 ..... 11 .................
Test Pit No. 2 ................ minutes per inch Depth of Test Pit .................... Depth to ground water ........................
------------------------•----•------------------------------------•-------------------------•---------------------------------------- -------------•----
Descriptionof Soil -------------==-------•---•=---•--------------...--•-----•--•------••---------------------------...-------------------•-----------------.....-- •........
----------••------------ •-------•------------•-----------•-------•--•-•------•----------•---••••-••------•----•-•----•---- •-----•-------•-----••----•----....-•-----------------------------------------
Nature of Repairs or Alterations —Answer when __:____
- i_Q_n__L.�n
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1E 5 of the State Sanitary Code The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bpisAuAb bo rd of health.
Application Approved By ...... W.'rowind
"___
Application Disapproved for the f oreasons: ____
.... _._...--•----------•-•............. .................•••-----------•--•--•-----------_....
Permit No..----. - ----------------------
(0
D 0
Date
Date
Issued-.......... . -l.. -- .`�.------•--------
D
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................OF...........:.. .............................
Tntif irat a of Tompliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by............ .-----•-------- ........../,.. r c'----------------------..._...-----•-----••--------------------••----------•------------._.._...---...........•-------•-- .-_.... _
-- Installer
at............ �------- -------- --------------`------------------' Z ......................................................................................................
has been installed in accordancwith the provisions of TITLE 5 of The State Sanitary Code as described 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................................................................................ Inspector.