HomeMy WebLinkAboutApp-Permit-ComplianceNo....Yuic . ...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...._._.._...�o wig(.------.---OF....Y RMO41. `'`f .....................................................
App iratinn for Dhnp aal Works Tunstrurtion Vrrmit
Application is hereby made for a Permit to Construct (& or Repair ( ) an Individual Sewage Disposal
System at:
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Loc ti - Address or Lot No.
.............fJ-�v p-----. � l� ��� V �.. �'• �1:. r �?k 1 Z 3�t.. E�9 ?'T .1?....._.....
Owner Address
•-------------------•-
a
Installer Address
M
Type of Building Size Lot ..-.1.. A._! ... Sq. feet
U Dwelling— No. of Bedrooms ............ 3 ............................Expansion Attic ( ) Garbage Grinder ( )
Other — T e of Building No. of persons ............................ Showers — Cafeteria
Pa Other fixtures .-___--•---•-•----_-•__--____._ . _
W Design Flow -.-------•---------------- - ......... gallons per person per day. Total daily flow ......................... 3a. v...._..gallons.
WSeptic Tank —Liquid* capacity/A00-gallons Length.8__ 7 U. Width__¢_'.___=/.d.__ Diameter ................ Depth -4._.-_.._..
x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ------- 1------------- Diameter... .. 1 /... Depth below inlet_...__..._._._. Total leaching area. Z l -----sq. ft.
Z Other Distribution box (x) Dosin tank ( ) 1
Percolation Test Results Performed by._ W 5Ts E ..................................... Date..... l _ ¢..._......--•....
as Test Pit No. ll-,1-Ui?' _ ninutes per inch Depth of Test Pit... 14-.4__...-_ Depth to ground water../��l._ ! ('
f� Test Pit No. 2 ................ minutes per inch Depth of Test Pit .................... Depth to ground water ........................
•-••••------•-•-----------••----•--••-••---•------••-••----•-------------------------....--_-_-•--••.........................................................
D Description of Soil--.------- _1 L?tu'1....s�!4 IVA ..... V. i ....... /LO.....f'U/7e.dtC-_.
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Nature 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 TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bpeh issued by the board of health.
�iig_... ._................................
Date
Application Approved BY-------•`-3--`-5---�-----
.......-----
Date..............
Application Disapproved for the following reasons_ ________________ _
Date
Permit No ......... Q..X -------------------•-------- Issued ............ Y
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
I-er�ifirtt#r oaf f�rrnt��i�nrr
THIS IS T,0 CERTIFY, �,T�hat the Individual Sewage Disposal System constructed ( or Repaired ( )
by-----...
1/• ... ,
Ilnstal
at........................................... --`--- - ------------------ ----------- ---- -- ----------------------------------
has been installed in accordance with the provisions of TITIE 5 of The State Sanitary Code as described in the
applicatiori'for Disposal Works Construction Permit No............J�-,................ dated ----- _ _._..__._ ..-----------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE......... 4 -:.! ? 5 �?..-70.P------------------------------------------------ Inspector........ ---•----- --- •------------ ---- •.............