HomeMy WebLinkAboutApp-Permit-ComplianceNo. S7-sod------ Fizz.....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
Z? - ............ OF ........ .........................................
Appl ration for Disposal Works Tonstrur#iun jrrmit
,Application is hereby made for a Permit to Construct
System at:
.....a�?1�...1�: �••.. ...... ...............
Location- Address
Owner
..... xi -a ..... Q_kj-�Q..C..•••...•-•-.....-••-••......-•...................
Installer
Type of Building
Dwelling — No
Other — Type
Other
) or Repair (-- fQ an Individual Sewage Disposal
Lo i -.S t V-f�aG-s
or
--•.�A.9........
. Lot No.
N........................................
Addres
.... Kaj.,).,bTA& jL -------•---------------------------
;Nress
Size Lot ............................Sq. feet
. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
fixtures------------------------------------------------------...-----------...................--------------...------------.....---•-------------------------
Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid' ca.pacity............gallons Length ................ Width ................ Diameter................ Depth ................
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area ...................sq. ft.
Seepage Pit No ..................... Diameter.................... Depth below inlet.................... Total leaching arm ................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by .......................................................................... Date ........................................
Test Pit No. 1...............minutes 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........................
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Descriptionof Soil-------------------------------------------------------------------------------------------------------------------
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NatureX's
Repairs or Alterations - Answer when applicable........- ..--.-. I ... v i..f?' �t rub 'Z....
............ ..... lf-b2�?....5:. 7* ----
f *----- i--------------------------------------------- .--------------- ..------..--------.--.-.---- ----.-=----------------------------
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITA IE 5 of the State Sanitary Code — The rsigned further agrees not to place the system in
operation until a Certificate of Compliance ee issu by a and of health..
Si /..i--- ......... ...'a_.=FS?..
Date
ApplicationApproved By ---- -- ........... ..............................................................- - • �... _ � .....
Date
Application Disapproved for the f 0wing reasons:
PermitNo --------------------------------------------------- -----
Date
Issued................ .-----•---•-••----............ .
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH �, r
...:. � .............. OF ...Y i !� N. Lx t i. !............................................
t.`
Trxfifiratr of T%ntplinnrr
THIS I$ZO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
f
taller
at Zf
- T ? - - -----•-•------
has been installed in accordance with the provisions of TITLE 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--COOK71tUE1) AS A,' GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY
DATE ..... ,ej --- nsco�',s�:'--•---.