HomeMy WebLinkAboutApp-Permit-Compliance, Sketch on BackTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......................... OF .....................................
AIuation'Ior Disposal Works Tons rue#iun Hermit
Application is hereby made for a Permit to Construct ( ) or Repair (V�lan Individual Sewage Disposal
System at:
................_
.510 !iS ............ .......----------------...- -..----.......- Lo -N ..
........_......
.................... ...
Location - Address or o
•---•--....�!:� .�.+�� ... G �.b h ................. •----.............------•......---. ......---....-•....... ... S Y� ru-..._................................ .._...._........
Owner ! Address
J .. Q V3 ari `b tE w S e ....... PASS = SS
Installer Address
Type of Building Size Lot ........ .•------------------Sq. feet
aDwelling —No. of Bedrooms ............................................ Expansion Attic ( ) Garbage Grinder ( )
04 Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
04 Other fixtures ..............................................
W Design Flow ............................................ gallons per person per day. Total daily flow ............................................ gallons.
WSeptic Tank —Liquid ca.pacity------------ gallons Length ................ Width .......... ...... Diameter ................ Depth ----------- .--:.
x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area -------------------- sq. ft.
3 Seepage Pit No--------------------- Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by .......................................................................... Date ........................................
1.4 Test Pit No. 1................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
W Test Pit No. 2• ---------------minutes per inch Depth of Test Pit .................... Depth to ground water ........................
....---•--------------------------------------------•--------------------------..............--.........................................................
Descriptionof Soil .................... M -El-.. ---A.................................................................................................. -....................
--••------•----------------•--------------------•------------............-•-----•-•----............. • •.
Nature of Repairs or. Alterations - Ans ier when applicabl
...............pl.4i ._..• .......2...--.. AE ... ...... -•----
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Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE S of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Complian,¢ en issued- the boardqf health.
Application Approved By
Application Disapproved for 6*0�`f ollowiofg reasons:
Permit No ......... 0-7 -- 0\ --- �--.............
..... Issued.......-.-.!
—. _ . .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
dVA) ........................ 0F.....1.1..&AI..Y.7-H.....................................
---- ------ -- ---------------
ate
il0
Date
Date
�irr#��utt#le of (1%nt�rit�tnr�e �.,
THS IS TO CERTIFY_,_That the Individual Sewage Disposal System constructed�•�(a ) or Repaired (jt )
by.. C_.. �:!4!C_._... ......... ...................... t............................--..............................................._
i/ Installer
._A4f'%N_._. w(�' e?t`jD�-.1_a22J t�fJ1GlT -----------------------------------------------
has been installed in accordance with the provisions of T LE jj``�� of The State Sanitary Coe as d scr' ed in the
application for Disposal Works Construction Permit No._ f :. 7 .................. dated-- .1.1. .................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A EE THAT THE
SYSTE W i FUNCTION SATISFACTORY.
J
DATE--- ------- -`-...•....................................... Inspecto> ��%- !! hP ...._.._......._.
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