HomeMy WebLinkAboutApp-Permit-ComplianceN0:7
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....... ..OF..... f.[4tZrMv�,3� ,---------------------------------------------
Appliratinn for Disposal Works Cnnnsirur#inn Frrmi#
Application is hereby made for a Permit to Construct ( ) or Repair ( clan Individual Sewa�e Disposal
System at: 1--0T Et S
......;._»»i...!'4Y ......'1. --..._ G-S.'r................. ...... �/" - - - !`t!!► d :mak.....:. `r'a
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Location. Address or Lot No.
--....... �T-:.e»»»... n e_, •--- 2v `-�............_........................�'`............................... .......................»...
o �.eer - (Address
......_...�xt:^ .......... \20 ✓��..... ....... — 1``t -" ......... .................................. - ... _....
Installer Address
Type of Building Size Lot ---------------------------- Sq. feet
Dwelling — No. of Bedrooms......................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures.----•----•----------------•-------•------.............--------------------•-••----...--------------........------............----------......._------
Design Flow.........��:..................gallons per person per day. Total daily flow......�.`.3 C2 ........................ gallons.
Septic Tank — Liquid' capacity.tQ.w.gallons Length.... V....._. Width ---- 4........ Diameter..._............ Depth ................
Disposal Trench — No.
... .1 .............. Width ...... 9%.--------- Total Length..._ .!.... Total leaching area ................... sq. ft.
Seepage Pit No ..................... Diameter.................... Depth below inlet .................... Total leaching area ................. 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..__.2 e- uy ..--_C eS..<�ll5.k�...................................
..`�lsr'g .,..1� � o.Q.a.... cz_� . -ti yo�x x...6.0? 3 F AQ .;.c,ti--�.._:..._:...
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. A
Application Approved By----------.
Application Disapproved for the
- Date ._....._.._
Permit No.. 21-0 .. ................. ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....... ............. OF .......... t . .u. U^..u.�`� .6 ........................................
Trrxifiratt of fauntplittm
THIS IS TO CERTIFY, Th#.t tCe Inndiviqu l Sewage Disposal System constructed ( ) or Repaired
by.. .- r ............ .: ........ ....---.........- .--------........---•-----....... »....
I�taller
at.. - 3 ---- . -- ------------------------------...---. ............--
.-- . -•-• ..... .--
has been installed in accordance with the provisions of T TLE �` of The State Sanitar Co a as ribed in the
application for Disposal Works Construction Permit No._Y7.__.------------------ dated. . ..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT -BE CONSTRUED AS GU RANTES THAT THE
SYSTEM WILL FUjNCTI N SATISFACTORY. F� `,f f / �. /%