HomeMy WebLinkAboutApp-Permit-ComplianceNo � THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...t�..I........................OF.............Y1.`.LWQ ......................................
Appliration for Uispaa ti Murky Tanstrur#ion f rrutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at
1 .3 a&_\3k '-(71A---- T*: :: ......................... LaT. ...... P. ae--10(,
i Location -A ddress - '.- or Lot o.
Owner Address
W
Installer Address
Type of Building Size Lot ............................Sq. feet
aDwelling — No. of Bedrooms ........ 3----_-_-----•----------------Expansion Attic ( ) Garbage Grinder
p, Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures --------------------------•-•---------------...----.._....------------------------•---------------•-•••----•-...-----------•-•-•--......-•••----•.....
W Design Flow .............•: 55.........---.....---._ gallons per person per day. Total dail flow......._ � �-----.-...-:-----. gallons.
g P P P Y y �` -•••• .
WSeptic Tank —Liquid capacity./P?99 gallons Length...... ._.. Width............ Diameter ................ Depth.--5?--------
x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ....... I............ Diameter......:? ........ Depth below inlet .._............ Total leaching area --�6:A.
Z Other Distribution box (IC) Dosing tank (
` 4 Percolation Test Results Performed by ----- :.Y .... _cd E----------------------------- Date..�� k-.g S........--..........
1.4 Test Pit No. L---_-..._.minutes per inch Depth of Test Pit ... J.TQ�...... Depth to ground water ..... 0 Imo......
Test Pit No. 2.---..�...... minutes per inch Depth of Test Pit ... A-4t....... Depth to ground water.......41
.................
p4------------------•--_........................-----.........._..-----•......_......-•-•-•..........................................................
O Description of Soil--------- ........ tu�-------------------•------.-------------------------------------
U -----------------------
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-----------------------------------------------------
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---.-.-------------------------------.----•.---------------------------
W.......--•----•-------------------------------------------•----•------•----------------------------------••---------------------------------------------------------.......................---•••---....
VNature 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 TITL% 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
p of Compliance has been ' b%o�rd of �h1eq/
operation until a Certificate Signe .. ........... Z-------- L..... _ .
Application Approved By..,. --- --......... ----------•--------------- , e
Application Disapproved for the following reasons: ..........
-•••-•-•---------------------------••----------------------------------............-----•-•
Permit No ..... �-�----XL.................................
ate
............................................
/ ate
Issued 1 ,..........
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O,F HEALTH
..... ............... OF ......... f��tJ�i� // l ely� ..................
(irdifiratr of f1 omplittnrr
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed Vf or Repaired ( )
.. -------- K-•-x•---------- ....... r r......-•------....-•----•--•---•-----•-•-•-•-------•••---------------------•--............•••-••---
has been installed in accordance with the provisions of TITLE
j of The State Sanitary Code: s de ribed in the
application for Disposal Works Construction Permit �'o..-�-=-.,7.--•--•---------. dated-...---/ --� .fa ...................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A4 A GUARA EE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. --� 2
f ��y
DATE........ :..1..:.(........- Inspector`'�°_�.�i_--_;n. ;...r ......................