HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD jjQ� HEALTH
......................----....-----.....OF....../...............................----...._..---........
Appliration for Utoposal Works Tonstrnr ' In ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at -
................._..� .? ntl-a......----------------
A,,f fi A Lo 6iZ.�,A/dress
v Installer
Type of Building
Dwelling —No. of Bedrooms ................ ...............
Other — Type of Building ........ ............. No.
Other fixtures ------------------- ------------
L- a- O
---- • r •....................5--...- - t�--s.�........
Lot No.
---------- ......LEA ............................................. .......
- ress
t t�-------- -.....
- -- ---- ----
Address
Size Lot ............................Sq. feet
.._.Expansion Attic ( ) Garbage Grinder ( )
persons ............................ Showers ( ) — Cafeteria ( )
Design Flow------------------------Val-----gall person per day. Total daily flow --------------- ----------------------------- gallons.
Septic Tank — Liquid cap....gal o ength................ Width................ Diameter..__._.......... Depth................
Disposal Trench — No......W' th................... Total Length.................... Total leaching area.._.................sq.Seepage Pit No..................te ................... Depth below inlet.................... Total leaching area..................sq. ft.
Other Distribution box (Dosing t nkPercolation Test Resultsrmed bY-------------------------------------------------------------------------- Date..... ---------------------•-------------
Test Pit No. 1...........s 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........................
Description of Soil----------------------------
Nature of Repairs or Alterations — Answer when appliFa.ble../�C/__-._,��_.._,-l/v ......... ............
.-----•-------•-------------•--------------.._.....-•--------•-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIZ 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 bogr4 of health.
Signed.... ------------- --- ..... _....
ApplicationApproved BY ........ .... -• ----• ........... -------•---------------------------...---••-.. n _ ...........
a
Application Disapproved for the f ollo g reasons- -------------•-•--------------------------------------------------------------•-------••-----------._........-
.................•----......------------••-------ti------------....----------------------.....------......-•-------•----------------- •............---.._..--------.--..............Date.----...------
Permit No.�� --a�----------------------•---•--•-•--• Issued4�` .-- ----- ii;2..............
�) THE COMMONWEALTH OF MASSACHUSETTS
04- BOARD OF AEALTH
........................I ..... OF ....L ..........................................................
Trr#if ira of Tom ittnrr
THIS IS TO CER� at the It�_Z.
idual Sewage Disposal System constructed ( ) or Repaired
•-------------- "L......... ------ --- ..........I------------------------------------------------------------------------------------------------
by
I tarter �
at ........ ........... -a� /V 1 %T� �-•----------.
has been installed in accordance with the provisions of T T��' S off The State Sanitary ode as�clgsc ' in the
application for Disposal Works Construction Permit No..`'agl'................ datedG�.Zj..._,____...
THE ISSUANCE OF THIS CERTIFICATE SHALL
SYSTEHT,7 ILL F N/CTION S�/ATISFACTORY.
DAT�'/.I... ...�-15-11 �.S)...................................