HomeMy WebLinkAboutApp-Permit-ComplianceNo.'
THE COMMONWEALTH OF MASSACHUSETTS
--�-- BOAR® OF HEALTH
............ ........ OF.........z91011..0a7G /---------------------------------------------
r'
�an
�ila Repair ( Individdal Sewage Disposal
, ppliration for Uisvoiial Works
Application is hereby made for a Permit to Construcl
System at:
................ __... 4 ....... 0 '0 -
Location - Advisees
---
.............
..............40iLll �-- -- Owl✓L-�------------•---•----•--•-
) or
Fss ..............................
... yzox7 . . ...............--- ------------- • - ._..........
or Lot No.
......---- •--•--...--• ..............................•-
Address
Installer Address
Type of Building Size Lot ___________________•._______ Sq. feet
Dwelling — No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No, of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures .-------•-•------------•-•-•-----------•----•---------•------------------------------------------•--------•--------------.....----•---•-•---....•-•---
Design Flow............................................gallons per person per day. Total daily flow ............................... ............. gallons.
Septic Tank — Liquid capacity ............ 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 area .................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percoiation Test Results Performed by .......................................................................... Date ........................................
Test Pit No. I................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 -•-•-------------------------------------------------•------.........._..------......-----------....-------•-------------------------.._._-----
..------•-•--•-•--•--------•----•---------------------------------------------------•...........------------------------------------•----•----------• ...................................................
........................................... ----•------------••---•--•--------•------•-----------------•---------•-----------------•--------•-•----------------------•-------- --------------•---
Nature of Repairs or Alterations — Answer when applicable._.____,__ZZ�:7;ioK_ -..._1.?._... ___ ...............
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLL 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.
Signe e er----- --
Application Approved By.d.____ _ :....:?..
��Officer
Application Disapproved for 4791)o' hng reasons: ...........................
.... ................................
Date
Date
PermitNo .........................................................
Issued........................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
'-ate j
........1 .. . ....... OF ......... `..fl!!7d.(t...........................................
(9rdifiratr of TuntpHaurr
THIS-)IS,TO CERTWY, That the Individual Sewage Disposal System constructed ( ) or Repaired
at......... o•-=°•--'-----_-- � �� � = :_y���,/.l �----yk� �--•------ ''� ' f ----------------------- --------•-•--------•-------------------___•--•----------
has been installed in accordance with the provisions of TLs 5 of The State Sanitary Code sd cribed in the
application for Disposal Works Construction Permit No.-_�7__��3•............... dated._,_`?7/z�e-Z,? ..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................................................................... Inspector -------------------------------------------------