HomeMy WebLinkAboutApp-Permit-Compliance Unit #2No ---- FRIE ... ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............. . M --- wll'�
..4 ....... OF ............. ...........................
Appliration for Bhipaaal Vork,5 Toustrurtion thrutit
Application is hereby made for a Permit to Construct ( --j-6r Repair an Individual Sewage Disposal
System at:
.......... --- ----
................. .......................................... �E ...............................................
Location - Address. or Lot No. _'� I I
Owner /V-*tVA%-'*C� e'4c- 75 Address
_100� I.,. "f'a i
..... ........ .... ...
Installer IT ;k, Address
Type of Building Size Lot_ lk___16
_Sq. feet
Dwelling — No. of Bedrooms --------- ............................. Expansion Attic Garbage Grinder ( )
Other—Type of Building .......................... .. No. of persons_______.__._____._______.___ Showers ( ) — Cafeteria ( )
Otherfixtures ----_---------_-- --------------------------------------------------------- * --------------------------------- * ----------------------
p- 'el Ffg On rp^e r
Design Flow ........................ 1.1-0 ......... gaiions day. Total d�ily flow ............... . .......... gallons j
Septic Tank—Liquid capacity-NA-C).gallons Length --- Diameter________________ Depths .__+.'.
Disposal Trench — No_ ____________________ Width_____._.__________ Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No -______I____________ Diameter ........ Depth below inlet___________.____ . Total leaching area._4Rj.0.7.sq. ft.
Other Distribution box ( -r-- Dosing tank(
Percolation Test Results Performed .... Date....
Test Pit No. 1_. G�.lninutes per inch Depth of Test Pit____ ... Depth to ground water_________________-___.
Test
ater...........--------
Test Pit No. 2 .... ....... ... minutes per inch Depth of Test Pit_____.__________.__. Depth to ground water________________.__.___.
---- -- ---- ------ ---------
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Description of .... ..... IOJ91�5_
t — --------_---
.3 . ....... --- , ... . ......... j::�*Aq ..... . M.E.2DW. _%� ........ . .......
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Nature of Repairs or Alterations — Answer when applicable ...... .................................... __ .............................. ..................
.............. .................................................................... I ....................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T IT 1E 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 spy the board of hqdi*.
Application Approved By
Application Disapproved for the following reasons:...
...... ......... ..........
Date
.............................................................................. .......................... I ---------------------------------- .....................................................
Date
Permit No. ---R2' .-2 ---------------------------- Issued_ ........ ...............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............. 0.f Von ....... OF.. A'rl .......................................
dw Z)�6
Qwrtffiratje of Toutpliaurr
THIS IS TO CERTIFY, That the, IndividuA SqVage DispXal System constructed (L-j"or Repaired
........... L(�a_ � (-�S � I.Ft.11,
at--- ---- t,.v ....... .. . ................
has been installed in accordance with the provisions of TIT IZ 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ...... ----------- R-0 ...............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......... ..................................................................... Inspector