HomeMy WebLinkAboutApp-Permit-Compliancei' No..C..l�......1.3 J F$s....... � J _
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEAL H
......./�l-,.�1.............OF.......................................................
y
Application for Diupouttl Works Tonotrurtion jermit
Application is hereby made for a Permit to Construe
System at
-D gvaoerrias+er t2ow
i ation -.,Al dress
?:.r.................................
.-- A.*1 7- \ °" s it ....................
Installer
Type of Building
Dwelling —No. of Bedrooms ....... 3.
Other — Type of Building ................
Other fixtures
( ) or Repair ( an Individual Sewage Disposal
...................... ..-..... :.!'�'!l9_�'- .1. �.__......._..
.___ ..
0
or Lot
•- Addr
Address
Size Lot ............................ Sq. feet
..........................Expansion Attic ( ) Garbage Grinder ( )
....... No. of persons ............................ Showers ( ) — Cafeteria ( )
.----••-•-•-•............................•---•-•---•--...--••----•----•----...-•--------._..........----•-•---•------•--......._.........------•--••--
Design Flow ............................................ gallons per person per day. Total
.._dam..flow ............................................ gallons.
Septic Tank — Liquid ca aci _6 .0 lons Len�._ .�..Width---..�......
Diameter ................ Depth ................
Disposal Trench — No .................... Width.................... Total Length gth....___..........._, Total leaching area _................... sq. ft.
Seepage Pit No ....... �.......... Diameter ....... Clt.X6 Depth below inlet ..... r!�_�_........_.. Total leaching area._a6.'7._...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 ........................
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
Descriptionof Soil ......................................................................................
.............................................................................................................. -•••-----••----- -••---••-------•-•---•--•-------•------------•---
Nature of Repairs or Alterations—Answer when applicable_ __ �°f�L�4G'G'.QG__,SFAs?fJ....V_✓/__?.'fz_r........
_.A.1..Q�fQ..�1���_.�r��11 e�..t,r9..�t. X�'..1�1..�.rrr�`"�.� S%fl�1t �.....-•--•......................................................................
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.
Application Approved
Application Disapproved for the
-----------------------------•----.........-•-----......-----...----•-•---•-•---.....__._...•--•--••-•-
Permit No ......... _�-6-.. _.I R 5— ..____---__
Dat
�DYte
............................ -------------/..•----••-•-----•••--------•••
1.7• � -
Issued --------------3 ...-..
% THE COMMONWEALTH OF MASSACHUSETTS
o /
;BOARD OF HEALTH
........1...6�.-4.......... OF ........... .'.!:::..�lf .
(arrtifuttte of Tuutplianrr
THIS U TO CERTIFY, That the Individual Sewage Disposal System constructed (z/'ror Repaired ( )
by........ t'_L�:_l /...................... _..........................
at ................. ''_.fr..._..._.is!�i
has been installed in accordance with the provisions of
application for Disposal Works Construction Permit N
THE ISSUANCE OF THIS CERTIFICATE SH
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............?. y ---•-'- •---•--------------•---._....---_-•-
-._..._..--•...... --•---•--•---••--•-----•----.._....•-•--•----•-•-- ......
- -•--- ---------
TIT F 5 of The State Sanitary Code as' de • ibed in the
o.-- ..�� -' dated-...----== n .V ............
ALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
r
Inspector-.,,. ...'_- `' = - .- �', _ _ • - ....:.
-f