HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
70W!I................ OF......l 1,Q0V r'4 -...............................................
Appliration for Disposal Warks T. nstrurtion Prrmit
Application is hereby made for a Permit to Construct (',)() or Repair ( )nan Individual Sewage Disposal
S stein at ....._ - ....... ..-•-•--»! V L » _- ...... • ..........
........--» .. •--•--•--•... ........... --- `` ...-
a i r Lot No.
........... � .._..c:xfzat�.�r.P d2i�C� )TAX /2Y� W�J'T L�E�i�e3 11,4-
W '� Owner --------Address
Installer Address
Type of Building Size Lot.__......,j.............4-7 ....Sq. feet
U
Dwelling — No. of Bedrooms ---.......... _.......... Expansion Attic ( ) Garbage Grinder ( )
p•, Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
a Other fixtures ............................
W Design Flow .............................%.' -.4 ._gallons per person per day. Total daily flow __-_-.---------------5a .0. -.-_--_gallons.
WSeptic Tank —Liquid'capacity$_O.O. gallons Length.?..�_-6U._ Widthl�71A" Diameter ................ Depth_'. _"¢'v.
x Disposal Trench — No- ---------------_-- Widtl .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No._._4 ............... Diameter..C._. f' 2-1 ... Depth below inlet.. .......... Total leaching area.Z.6 ....sq. ft.
Other Distribution box ( K) Dosing tank /
ZPercolation Test Results Performed by....T.W. '!� �.-•----------------•------•-•--------- Date ... A:de
Test Pit No. 1 L`%`�__f ZZminutes per inch Depth of Test Pit. -1 _` '*!f -.. Depth to ground water./Tz.............
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
•----•-•--••--•----•---•-•••••--------••--•-•-......•-•••-•--•-••.....•-•---•------••--•--------------•--'-...............W- ..
D Description of Soil ------ �% �•--p 6U!( T`b /�/Jif�F� 6 ,��f/b U.vd .---3 0 `` ,�D!!.......----•-
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W...................................... -----•--•------------------•---•-•----•----••••-•'------•--•-----------------•------••--------•-•--------------•-...---------•---••----•--------'•-•--
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
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Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance ha been issued by the board of health.
49 Si--------------------------------------------------------------------------------------................................
�, A lication A roved B r ... I
PP PP Y --V.,7----- --------------•-----••------- -/ ............
Date
Application Disapproved for the f oll ing re on
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..............•-.....----....-----------•...--------•••-••-•-----••-•-••--. •-•---•--•-----•-••-••-•-•••-------•-----....-•-•--••---•-•-••-•----•------------•-•--•......--•-•-••--•-
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Date
PermitNo ......................................................... Issued .......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
f !rtifir ate of (� t rlt�tztr�e
THIS IS TO (;ZkTIFY, the Individual Sewage Disposal System constructed (x) or Repaired ( )
bY- ------ --- -•-•••-•-•-------••---....--
at`<, .-------------•---•--••-•------•----••------•••••---»=- --- ---------------------------
has been installed in accordance with the provisions of TIT�j,_5 of T State Sanitary Co /r �d in the
application -for Disposal Works Construction Permit No ......................................... dated ............... ../..._...�.._........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................................................................... Inspector