HomeMy WebLinkAboutApp-Permit-ComplianceT Ll vm
No. ................. soU$i1, �ilteQe iiy f,.4 c�ii'i it * F�............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. ........................ ----.---.---......0 F..........................................................................................
, pptiratiun for Disposal Warks Toustrnr#inn Verntit
Application is hereby made for a Permit to Construct (� or Repair ( ) an Individual Sewage Disposal
Sys
at: �1 � .... .-----/.....
U --Location:.Address-----------or-I.ot No.
... .... ..............._....._-.._...-------•--------•.._.._._....-•-•-•. ............. - - --••--_.......•----....._._..........--.......•---
-% �, iJ Owner Address
Installer Address
T of Building Size Lot,.= ..... Sq. f
Dwelling — No. of Bedrooms ______�_........................... Expansion Attic ( ) Garbage Grinder (/0
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures------•-•..........................•--------•----......--------------._._..._..-•--•--•----..._......_....------•---------------------------........_.
Design Flow ........... 1.tln_______________________gallons per person per day. Total daily flow ......... . .................... gallons.
Septic Tank — Liquid capacity/L1-4?Mgallons Length ---------------- Width ................ Diameter ................ Deptl_�?<,..
Disposal Trench — No . .................... Width .................... Total Length .................... Total leaching area _
. _v._...sq. ft.
Seepage Pit No ---_------------ ameter.................... Depth below inlet .................... Total leaching area ................. sq. ft.
Other Distribution box (.e Dosing tank ( ) l q -
Percolation Test Result 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 ........................
Description of
.........................
..............................................................................................................................
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 4 health.
- Sig -•-- -----C .. .•............. ••••••............••... •-/� a =S�
.............. .. ..................
Application Approved By.._.. .. � `� - 5
Date
Application Disapproved for the following reasons: ....................................................
•-----•----- --------- -----------•-__ __ _---•_...._......--•-•__ ___..._.._.
Permit No ......... �_., �? S ......... ...._
Date
...............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O/ HEALTH
Jc........ oF.,l...... 11. -Ct.. .......................
Trr#iliritr of Tomplinurr
THIS IS TO CE�TIFY, That the IndividualSewage Disposal System constructed Repaired ( )
has been installed in accordance with the provisions of TITLE lj
application for Disposal Works Construction Permit No.____'._'�..�
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE
SYSTEMA WILL FUNCTION SATISFACTORY
t
DATE--------f -�............................................................... Inspetto
C `'
of The S to Sanitary e,as des ` ibed i�1 the
.�. z. dated__.. �--•-----•-
CONSTRUED`AS A GUARANTEE -THAT THE
Fims..... .....
THE COMMONWEALTH OF MASSACHUSETTS
¢OA�RD F HEALTH
Appliratiou for Disposal Works ustrur#iun 11r mist
Application is hereby made for a Permit to Construct
*:?__Sys!m. ' M --------- ..... ... 1.
—Location - Address
.................... .._........................ .. ----•--
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N.. ---.--- ----------------------------------------
aInstaller
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or Repair ( ) an Individual Sewage Disposal
;641C .16 . ..................... ...................................
or Lot No.
Address
Address
Type of Building Size Lot.._22i. z .....Sq. feet
Dwelling —No. of Bedrooms .......... 3 ..........................Expansion Attic ( ) Garbage Grinder
Other — Type of Building ............................ No. of persons ---------------------------- Showers ( ) — Cafeteria ( )
Other fixtures .---------------------------------------
Design Flow )/......_._.. gallons per //dam. Total dailyDflow a11o1p,
Septic Tank — Liquld capacit3j._/P�g llons Length.- _._( ..... Width....... _.._. Diameter ................ De th__�3.__...__.__..
Disposal Trench — No. .........
-------- Width ...... q.......... Total Length ........ Z2... Total leaching area.2_........... sq. ft.
Seepage Pit No ---_-_---_------- D' meter............._...... Depth below inlet .................... Total leaching area ................. sq. ft.
Other Distribution box ( Dosing t r ( r" ,r1 �f
/ C.J fir! �-'
Percolation Test Results Performed by..... _....------------------------------ - ---------------- Date ____ Z. .____ _....._�.�
Test Pit No. 1.4...2:minutes per inch Depth of Test Pit ... .------ Depth to ground water...._. -1 ..........:...
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
---•------•-----------------------•-----•--•--------•---•--..........------------•-•-•-.......---•-- ..............--•-----
Description of Soil-- �` d{�5__�PY_ SK81�tL J Q
sgWr� ��` i ��.�.�� f�i-��l 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 agre s not to place the system in
operation until a Certificate of Compliance has been 's d by the board of 1 L
Signe 75_ZJ
- -- - --
3I zz� -5
Application Approved By.. --- . � ... ..........
Date
Application Disapproved for the following reasons----------------------------------•--------------.....---------------.-.-•-----------------•-•---------•---------
---•-.....----••�---••.................••---••--•••---•......--•--•....._.......... .......................--•-•-•--..Date--•-•----••---
Permit No..._.! Issued.....`�..(•2�'.. �s
..-•---•------------------•----------^---• ---Date ------•-------......_._._._....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
(
....................:..................... OF .....................................................................................
Tntifiratr of Toutplittnrr
TIS, IS: TO CE TI Y Th the IndiL ividual Sewage Disposal System constructed (A or Repaired ( )
,
by.... = -----------------------------------------•--.....--------...- .....
Installer
-------------------------------------------
has been installed in accordance with the provisions of TITLE `" o The State Sanitary Coe as described in the
application for Disposal Works Construction Permit No._��__^!o................. dated...3. ZZt{._ ��..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.................................•--------------........------......---•-•...... Inspector