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HomeMy WebLinkAboutApp-Permit-Compliancee-_k_� V !'t _1 1 �C No.. �..----._,_..... C� � 1. � Fps. �:.��...... �•� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH A.VVIiration for Uiopo a aj Works Tonstrnrtion Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal ystem at: ...., lG��,v:....-! eie .... ell..... :..... -1�- .:.../ ?/ °r�_T ___ __ I_%_'._r� 3� .... Location - Address or Lot No. - -- OW Address a ..------.. :. -...............................--------------------- ,�r. '1 Installer Addre U Type of Building Size Lot._ j�_. �..Sq. feet Dwelling —No. of Bedrooms ------- S,.�------------- -------- -------... Expansion Attic ( ) Garbage Grinder ( ) aOther —Type of Building ---------------- ------------ No. of persons ............................ Showers ( ) — Cafeteria ( ) Other fixtures W Design Flow________, . ____________________________gallons per person per dajy. Total daily flow -------- `? ,7-6-----_-_------_-gallon WSeptic Tank — Liquid capacity./tf1e.gallons Length ----- .d 6---- Width ------ Diameter ................ Depth ..... :V.- Disposal Trench — No_ ____________________ Width_____ ...... Total Length .................... Total leaching area --_----_----.-------sq. ft. Seepage Pit No.-----__-_1-_-____- Diameter..._t ......... Depth below inlet ---- tP..._-------- Total leaching area.__ .-?.-Gv 7sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by__..7%"/?715_.__fi��_�._.1��Y_, Date_-.. 3 ►4 «ss 7AAnr r - M Test Pit No. I....,zc�sa .minutes per inch Depth of Test Pit_..r� __._.. epth to ground water ........................ (� Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water. ....................... --------------------------------------------------•-------------------...-----•----•-----------------•------••---•-..-- ----- -----••----••---.--------- Description of Soil----6--*'�---3-6 ............ m © d rrl't---� -- `s .................................. -----------------------------------------------•----•------------................................................. ...... --------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 TITLE 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 board of health. Signed.._.._ =-------------------------- Its./���� t f Application Approved By----- , ---- ......--•- ----• ----- • •-•-- ••----• � e •--------- - ater _ Application Disapproved for the following re sons: ----------------------------------------------------•---------------------------------------•----- -------••-----••-•----•••------------•---••---------•----•-------•-••••------------------•--------------------------------------------------------............. - -- ------- Permit No.......... ...___. �.----.to -----------------•-----------•- Issued ..--------•--------------�--- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............j ... ............OF.z!.......................................................................... Grfifira tr of T-ampliFanrle T�S ISTOC2TIFY, That the Individual Sewage Disposal System constructed ) or Repaired ( ) by- -... ........ _.............................................................................. -r-------------------- -----•-------........................ f j Install at........................ - -------- --------- - ---------------------------------- has been installed in accordance with the provisions of T� T,LE 5-of--The State Sanitary - odg as _flescribed 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...---- Ins - -'� --------------------•- ---•----.----- . Inspector