HomeMy WebLinkAboutApp-Permit-ComplianceNo-------- - I_-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......... ................0.... .... 41 1 ......................
Appliration for 13hipasal Works (foustrwtion 1hrin'd
Application is hereby made for a Permit to Construct (X) or Repair an Individ I ual Sewage Disposal
System at:
. .. ........... ......... ....... ............. ..... .......... ......................... x C?/ A y
.......................... .......... ... ........
Lo n, �Wress or Lot No.
...... ...... ....... .... . . ................ -•---------•••-----•----------------....-_- .......................................................
n ddr
,.3 7 w
... ..................
...... 2
........................... _J(
.. . ....... .............
Installer Address
Type of Building Size Lot ---
U .0 ..Sq. feet
Dwelling —No. of Bedrooms ............ 0 . ...................... ... Expansion Attic Garbage Grinder
�_l ......
114 Other — Type of Building ............................ No. of persons_...._.._.__._...___.__.__._ Showers Cafeteria
Other fixt ............................................................. ........................................ --------------------- ----------
uves .......
Design Flow___.____._ ........................ gallons per person r,�ay. Total dail/
X ';ow --------- 0 ------- 0 -------------------- goallons.
P4 Septic Tank — Liquid capacity/ZZ allons Length.&_'�n.. Width. -A/' ........ Diameter ................ Depth_5�'e
Disposal Trench —N o ..................... Width .................... Total Length__......_.. jTotal leaching area ------------ ....... sq. ft.
Seepage Pit No ...... ........... Diameter........._____ -0 --- Depth below inlet --- Total leaching area ... !K ..sq. ft.
Z Other Distribution box (,-< Dosing tank ( )
Percolation Test Results Performed IrdS105-.. Date-_/10/z�',
.............
Test Pit No. 1.2!!�Zminutes per inch Depth of Test .. Depth to ground water .................
Test Pit No. 2 --------- ...... minutes per inch Depth of Test Pit .................... Depth to ground water ........................
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Description of Soil ---C 0 ........... _56''. ( - -- --------
. ........... YC_70 ....... ...... _D-----.......'-----'
................ ......... .................................................................................................... ........................................................................
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 T I T 11 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance, has bee . ssued by the board of health.
,AD.0 D,
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Si e ............. ............. . ..... ......................... ----- ------ --- -------
Application Approved By -• -/ - ---------
D e
Application Disapproved for the following reasons: ................................................................................................................
........................................................................................................................................................................................................
Date
....... ....... ----------------------------
Permit No.._....1.. ------- Issued .... /ate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....... OF ......... ...................
(9rdifirate of Toutplitturr
TH I �FY
L� S TO CERT) hat the Individual Sewage Disposal System constructed (C-)-lor Repaired
by-----. .......... ----------------------------------------------------------------------------------------------------------
at > 7 ----------- /-./ .............. .......r' _/ .......
has been installed in accordance with the provisions of TITLF� 5 of The State Sanitary CodF. as jescribed in the
application for Disposal Works Construction Permit No .... 1- 1 / -)" i" �0----------------
dated ----- i ....................
. -.r --- ---------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector ................................................... ...................... ............