HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH ASSACHUSETTS
BOAR® OF HEALTH
ApPration for Uispoiial 30orkfi Tonstrn.rtion Vamit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
............. ..=--............ -
Location - Address or Lot No, 119 ,/
.... .........•— Address
��AA Owner �-----
Tf�C— .............. Installer — )a_....:. l .:. .._.__.._..
...................................
Address ,
Type of Building Size Lot__ �y, ��G`_________Sq. feet
Dwelling —No. of Bedrooms ......... Z_ ............................. Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ____________________________ No. of persons ............................ Showers ( ) — Cafeteria ( )
PaOther fixtures-•------•---•--•-------------------------------------- -•----------------•----------•-------•----------••-•----•----------•---------------------------
W Design Flow ____.____�_____
.......................... gallons per person per day. Total daily flow --- z_ ............................ gallons.
WSeptic Tank — Liquid capacity-!c'PtU_gallons Length__/e_C ___ Width._ ?_ Diameter________________ Depth ---
x Disposal Trench — No_ ____________________ Width .................... Total Length --------_--------- Total leaching area ---_--_---------- sq. ft.
Seepage Pit No ----- Z ----------- _ Diameter___.Depth below inlet .... 6_ZHE.... Total leaching area.. ...... sq. ft.
Other Distribution box ( ) Dosing tank ( )
'-' Percolation Test Results Performed b e -./& __ ... � ___ ���___ _ Date___/VoV__-fy-1 y�o
�lt5 by_e }
aTest Pit No. 1 __ ��____rninutes per inch Depth of Test Pit ... !--- ----- Depth to ground water_.___..._"®_____.__.
(i Test Pit No. 2 ................ minutes per inch Depth of Test Pit____________________ Depth to ground water ........................
O Description of Soil--- ,� �r,---•��"2���- � 5 '- � �---2�•r- 7.. �i_. �L _- 5 1.J-----------------------•
x amu- r�4/-i &,;c> a < �,� s a
v---->l -- •••------•-•------------•-- ----------•-••--•-••----------------•------•----•-
w----------------------------------------------------------------------------------------------------------------------------------------------------
UNature 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 �-..:.-
�'1T/-1 , 5 of the State Sanitary Code — The undersigned f rtl:er agrees not to place the system in
operation until a Certificate of Compliance has.been issued by board of eal q
Signera:'r^-R. ..-----•------ - ----------- -----
X/l/ e /
Application Approved By____:____ / /
Application Disapproved for the following
PermitNo ---------------------------------------------------------
ate
-----------/ -------•- ---------------_
Date
Issued--------------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
OARD OF HEALTH
:.................. OF .................................................................................
fit
Trrtifirttti� of Tompliatta
THIS I TO ERIFY, That the Individual Sewage Disposal System constructed ) or Repaired ( )
- --,-------- - -•-----------------------------------------------------------
er
at....... ,.......................... � T'_./'__........----- r�L--. - - s ------- G� ' -
has been installed in accordance with the provisions of T TLc; 5 of The State Sa ryYZANTEE
described in the
application for Disposal Works Construction Permit No._____� dated_.'9V
..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..................•-----•-------------..........-----•----......--•---..._-•---- Inspector __------------•-------------------•_____----------------------------------------•---