HomeMy WebLinkAboutApp-Permit-Compliance (Not Issued)17
No..... 1.!e ... ........ Fruc ..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
0 F .......
...........................
-P ........ ...
Appliration for Biap I i8arko Gans tion Prrutit
Application is hereby made for a Permit to Construct (for Repair an Individual Sewage Disposal
System at j
----------
a , Addre s r Lot No.
Z�) ------------ ----------------------------------------
- - ------ - ------------------ ---------_-- - ---
Owne Address
............. // ------- -- ............................................. ......................................................... -------------------------------------
Installer Address
Type of Building Size Lot ............................Sq. feet
Dwelling�o. of Bedrooms ....................... .............._.._..Expansion Attic Garbage Grinder (
Other —Type of Building ------ 3 ................... No. of persons ---------------------------- Showers Cafeteria (
aI
Other fixtures ---=---------------------------- ......................... ------------------------- ---------------------------------------------------------------
Design Flow ............................................gallons per person per day. Total daily flow -------------------------------------------- gallons.
04 Septic Tank—Liquid capacity ............ gallons Length -------_---_- Width___.__-__-.-_-. Diameter________________ Depth-___.______._..-
W
W4 Disposal Trench — No ..................... Width................._.. Total Length-_-.----__----_.___- Total leaching area .................... sq. ft.
Seepage Pit No. ----,9,. ----------- Diameter ------- r -------- Depth below inlet .......... --------- Total leaching area. -------------_-- sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Per -formed by .................................................................... .___ Date ----------------------------------------
4
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___.---.-.---___.______. . ........... ............................................................................. ...... .........................................................
Description of Soil___N
0 -------------------------------------------------------------------------------- .........................................................
. -------- ---------------------------- .......................................................... ------ --------------------------------------------------- ................
Nature of Repairs or Alterations — Answer when applicable ---------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI 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.
ned.. ....----------------------------------------------------------- ................................a
Date
Application Approved By------ - ------ ---------------------------- --- L
Date
Application Disapproved for the following reasons: ----- ----------------------------------------------------------------------------------------------------------
....................................................................... ------------------------------------- ------------------------------------------------------ ------------------------------
Date
Permit- ---------------------------------- Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
... . . ...... ...... ............. OF..( .............................
Trrtffir#�af Toutphaurr
CERT F-Yj �tliondivid'��al Sewage Disposal System constructed (Z --)"or Repaired
----------------------------- �:� --------------- y ------- ;::;--: ----------
by . .. .... .... ......... 7,7� ------------------------ 1-:7-
e c ed in the
has been installed in accordance with the provisions of Article XI of �T�he �te Sanitary C �' as
application for Disposal Works Construction Permit No. -.11-S-2 .................... dated-__
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A PRARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector---- L� ............. ----------------
A
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
92���
.............
.... . . . ........... OF ......... ....... ... . ......... ------ I ...............
N0 ... F]Ir� ............. ..........
Permissionis hereby granted ................. .. . ....... ................................................. ....................
to Con tr or it an Indiv dual eti
e Dis 1 Sy tern ,�77.110
................
----- - -----
St et
as shown on the application for Disposal Works Construction Per o. ated-_
.......... ------ - -- - --------- ... .. ...........................
Y
oa ealth
DATE---------------------------------------------------------------
FORM 1255 HOBBS 8, WARREN. INC., PUBLISHERS