HomeMy WebLinkAboutApp-Permit-Compliance - Unit 2No. d -.y-, 2. Fw3.-dk..2...............
THE COMMONWEALTH OF MASSACHUSETTS
�-�•-� BOARD OF HEALTH
...V--!..)............ OF ................
Appliration for Bii#uaal Vorkg Towi arnrtion rantit
Appli on is hereby made for a Permit to Construct ( N,)"`or Repair ( } an Individual Sewage Disposal
System at
}�� ...f.... ..� i(-<Tlec.----•--C-4-IZ 0lrg---......... ---------------------------------•-----�-�--
Location Address • i
_ , or Lot No.
Installer Address
— — ------------------------
Type of Building Size Lot._j_.D_�.q. feet
Dwelling —No. of Bedrooms ......... 7r..........................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ------------------------- - No. of persons....................---..... Showers ( ) — Cafeteria ( )
Other fixtures -------------------------------
Design Flow ............................ ----gallons p r d
er day. Total daily flow_..........._. _.
r�.��.-----------ons.
Septic Tank — Liquid' capacityf.Q Q.-Q.gallons Lengthl'--ta.".. Width... ----------_- Depth- -----
.
Disposal Trench — No. --------_------.-- Width .................... Total Length ............ _.._... Total leaching area ................... _sq. ft.
Seepage Pit No -------- I----------- Diameter.......[[...... Depth below inlet ....... Total leaching area.-..�S2J.-sq. ft.
Other Distribution box ( y--- Dosing tank ( )
Percolation Test Results Performed by ....% kJ. d' f2/J_�__--// ,_ Date_..j_L/ I/D•_Z,,,
Test Pit No. I......... L'minutes per inch Depth of Test Pit.--%-&- ."... Depth to ground water ... --------------J----
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water...................----.
- •. ...........................................................................................................................................................
Description of...........
..... ' Ol ......... --------------------•---- -----------------------------------------
'g ----------------------------------------
1 ------------ .................................................. ..............................................................
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 'AI TI.i:. 5 of the State Sanitary Code — The undersigned further a rees not to place the system in
operation until a Certificate of Compliance ha been issa d by the board —
igned--- ....._ -- - ----- .... --••-- -A
ate_
Application Approved By.- ----------------------------•........ .................. ..
Date
Application Disapproved for the following reasons-------------------------------•-------------------•----------------------------•-----.........................
................................................. -------------------------------•----------------------- ---------------------------------------------------------------------------------------
Date
Permit No. 2------------------------- Issued f -_>Z Z_.._ �,---------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAL H
.......... j...0 G,A r?!r ! ......... O F..... %.. ..±`.........................................................
J......................................
�irxtifirttb of Tnrnt�r�ianrr
THIS IS O. CERTIF That the Individual ew. Disposal System constructed_ (r Repaired ( )
r..
Installer
at. `- -c,= -----------------------------
has been installed in accordance with the provisions of TLS %" ;5,,,of;The State Sanitary C2d-e � rescr lin the
application for Disposal Works Construction Permit No ----------------------------------------- dated ------------------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. i .00
DATE.............. -----------------------------------=--- Inspector....?