HomeMy WebLinkAboutApp-Permit-ComplianceNo..... �:.. y� Fss......•
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
--------------------
Appliration for Uisp aal Works Towitrurtion rami#
Application is hereby made for a Permit to Construe
System at
Location - Add
......................__^""
-------------
a f Owner
---------------------------------
Installer
Construct
( ) or Repair ( ) an Individual Sewage Disposal
or Lot No.
Address
Address
Type of Building Size Lot_._Z��-- ...Sq. feet
Dwelling —No. of Bedrooms ............. .........................Expansion Attic ( ) Garbage Grinder—{
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Other fixtures ...............................
Design Flow .......................% ......... gallons per er day. Total daily flow.._-------� .
....................
Septic Tank —Liquid-capacaty/A�%�gallons Length '_4..- Width�,�:/ .."Diameter ................ Depth_- ::
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area ___.•-----------_--sq. ft.
Seepage Pit No ------------ /..... Diameter .... j40.e�Depth below inlet...... r?`. Total leaching area.. ..eZ- .Z -sq. ft.
Other Distribution box ( ) Dosing l
Percolation Test Results Performed by.__........t.J..: �'.._.._._.G________________ Date__... r ___
,� �.. .......
Test Pit No. 1---,--/.�?.. inutes per inch Depth of Test Pit__ % =1.-.__ Depth to ground water.._.lG_�G _.
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
4 --------------------- m.............................................................................. .........................................................
Description of Soil -------------2 = ~ Tem?vQS�a sG f =
------------------------...........�%i�2... d� `' .dam �.-r 'sL
jNature of Repairs or Alterations — Answer when applicable.................•...-__....__.._._.........................................................
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Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T IT 1:2 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. ... ................... . ��.. ... ...... . ....
ate
Application Approved By ................................. ------ e -----• 4 _...... ... ........
Date
Application Disapproved for the following reasons: -•----------------------------------•-•-----------------•----------------------------------------••-----•-------
-•--------------------------••-----....:-------------•--------------•-•---•------•----------------....----•---------•---•---------------------------------------------------•--------•-•-----• •-•---•---
Date
�a
Permit No.... .........�................ Issued--------- `vz�� to
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............. I ...... I .................... .OF .....................................................................................
Tatifirau of Toutplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal S7stem constructed ( ) or Repaired ( )
by
has been installed in accordance with the provisions of
application .for Disposal Works Construction Permit N
THE ISSUANCE OF THIS CERTIFICATE SH
SYSTEM WILL F CTIO SATISFACTORY.
DATE.... .. ...''
Installer
---.....---•--------------•----....---------------•-------------------....---•••----.........•-•-••------
TITI,r. 5 of The State Sanitary Code as described in the
o............ --------- dated---------- r S,: .. .........
ALL Pdd7 -li� ONS RITE® - Amt rAIARA`NTETHE
Inspector_`_-_