HomeMy WebLinkAboutApp-Permit-ComplianceNo..... :.. .. .......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................... .................... OF ................ _.......................................... -••-.....................
Appliration for Disposal orkii onstrnrtion Vamit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
Systeu at -4 .......... A4rll
Location - AdcI,ess or Lot No.
iJ a l 4 ! ' '�-----------•................. �..�.. rl ` �.� s --- :
-------
- ._.... ... ,fir
Owner /t'I/i� J' Address
�Q.... 5 .T� . 9..: 1._ .......................
Installer Address
Type of Building Size Lot ............................Sq. feet
Dwelling —No. of Bedrooms......... --------------------------------- Expansion Attic ( ) Garbage Grinder ( )
'. Other —Type T e of Building ............... No. of ersons._._......__..._._._........ Showers — Cafeteria
f� YP g-----------•- P ( ) ( )
aOther fixtures ---------------------------------------•---••---------.-••-•---------•------••••--•---•--•--••------•------------------.......--•---•----...-••-------
d
Design Flow ------------- ________gallons per person per day. Total d'ail�' flow__._..._.___..�1_��-'_......... gall s.
W Septic Tank — Liquid' capacity4�A.gallons Length.... ..._._ Width ... .-..._. Diameter ................ Depth__
,
x Disposal Trench — No..._/ .............. Width_��_ ._...... Total Length .... "�"Z--_... Total leaching area.. Z8- . _...s
Seepage Pit No --------------------- Diameter .................... Depth below inlet .................... Total leaching area .._.._._.......... sq. ft.
Z Other Distribution box (`� Dosing tank ( )
'-' Percolation Test Results Performed b .__ �=-?'....
h._.._. ._ Date...
Y - -... ..��-•------------ - }�f ....r¢.! a9-ram--
aTest Pit No. 1 ti------ njinutes per inch Depth of Test Pit..1 ---•- Depth to ground water ...........
fi Test Pit No. 2___c'__ ..minutes per inch Depth of Test Pit ..__.9>/ ----. Depth to ground water ........:........ ...
/a8y moo'
y< 2�--------------------------------------------------------------------------------------------------------------------•----------------------•---- ------
ODescription of Soil-•............................................................................ ....../y 8 & ---
V��--- ------------------------------------------••-•-•-------------•---------------............-------•----••------•---
----------------------------------•--•--•••---•-•------•---------...-----------•-•-••-•-••------••-----•--------•------------••------•-•••----------•-••-•--••--•-•....••---•-••-••......--------------
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 TITLL 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance ha bee issu d b the board of health.
qq
Signed•--- ------ ---• ----------•----•--- ------
Date
Application Approved BY---.�'s� . . ..
-----------------• •--
.........................................................................•• Date
Application Disapproved for the following reasons_ _____________ ........_____
--.......•.....-----•------•-•------•----------------------------•--•••••-•-•-••-------._...••••••---•••• ---•-•---------•-----------------...---•-•-••••-•••••--••-•----•------••-••••••••-•------•-----
z Date
Permit No ------- ___31 ...
�._.. Issued ------. = L �� ------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
i
OF....................................................................................
Trrtifirate of Tomptianrr
ICI$ IS TO CF TIFY_- That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
bY----• ----------------------------------------------------------------------------------------------------------------------------- •----------------------------------------....-• ...--•
% /f Installer
at.......................................... • =------•-•-••---------•••••------••••-----••-•-•-----•-----•-•---•---•----••-------------------------
has been installed in accordance with the provisions of TITS_ 5-of The State Sanitary Code as described in 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.
DATE-• =�•-- 1-- .----�---------------------------•--••-•---- Inspector-....,-.. --- '----------------•--•---=----•---------••--•---•-•.