HomeMy WebLinkAboutApp-Permit-ComplianceNo..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................OF..... 1 -1 'd: ;i> ............................................
Appliration for Dhipos al Works Tontruriion Vrrmit
Application is eby ma r a Per • t onstruct (X) or Repair ( ) an Individual Sewage Disposal
System at :
....: ••- gj - - --rK - l /% ; ' _. >.......................
............ ..-- ....
Location - Address p'// / oar/Lot No.
...... _.��.... ..L1�.Y._ ' -
................................................... -"'-- - --7-•---6.-1.T.7._..c..`., .............
Owner Address
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms______________________________ _ _ .Expansion 4,ttic ( ) Garbage Grinder ( )
Other -ZType of Building H)::'*f................. No. of persons ......... lrd_.......... Showers ( ) — Cafeteria ( )
Otherfixtures -------••------••-----------------------------------.---------- --------••-------------------------------------•---•--......--•-------......-•------
Design Flow ............. ./'..:r. ................. gallons per person per day. Total daily flow ........ 1 .0._._...._..........._gallons.
Septic Tank 4L Liquid capacity--/d,040gallons Length ................ Width-_____--__.--.._ Diameter ---------------- Depth ................
4 Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area --------------------- sq. ft.
'> Seepage Pit No. ........ r ------ ... Diameter.._. 1.7......... Depth below inlet..._ra_..Total leaching area_.01/-/P..W.-f`t'.
4 Other Distribution box (x) Dosing tank
Percolation Test Results Performed by ............................................ Date ..__...__.____............._.........
-.
Test Pit No. I ... 7....._..minutes per inch Depth of Test Pit .... �z._____._ Depth to ground water_ .. w&—.---__.
Ne a vWTcGe-o
i, Test Pit No. 2................minutes per inch Depth of Test Pit ............... ..... Depth to ground water ........................
Description of Soil---- ./_... -
------....-•---------------------------------•--........-------------------------•----------•---------------------------------------------------------
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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 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 i��sssu//e by the bo d ohealth.
igned. _.ltM _ 1
v 5 amu- - .............. 73,'� 7...�_....
Application Approved By------ �...
Date
Application Disapproved for the following reasons:...
PermitNo .........................................................
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Date
Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................................ I.,....... OF .....................................................................................
Tntifiratr of (9-amplianrr
THI�S' IS TO CERY7,f7 h, That ,the Individual Sewage Disposal System constructed
by, e° e t -- - --- - - --- -------------------------------------
,; t
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has been installed in accordance with the provisions of TI F 5 of The State Sanitary Cod described in the
application_, for Disposal Works Construction Permit No._ __ ."._ ��,j �-------- dated_-_.__,� ��2�._.��__.•......
THE ISSUANCE OF THIS CERTIFICATE SHYL NOT BE CONSTRUED AS A G GRANTEE T6�YAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
) or Repaired ( )
DATE................................................................................ Inspector