HomeMy WebLinkAboutApp-Permit-Compliance......�� Fps........... ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9F HEALTH
, AV---- .............. OF.-.-........��/.!!......i .....,...........7........------.._..------------
Appliration for Diopaoal Warks Tonstrnrtiun ramit
Application is hereby made for a Permit to Construct (s� or Repair ( ) an Individual Sewage Disposal
System at: �
Location - Address or Lot
-, -.�•'-------- -----------------
O,Address
----- fz�_ff .ice .l_ -wner ---•-•-- ............................... ... -----.......... ----...................... ..
Installer Address ,�^
Type of Building � Size Lot__ �/.Z I ..... Sq. feet
Dwelling —No. of Bedrooms____________________________________________Expansion Attic ( ) Garbage Grinder (V4
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures 2'"-�.�a------------sr...------------ •------------------••-----__________-•� ---•-•--••------•------
Design Flow .............. ................. gallons per;=P1r dC y. Total daily flgW---------••---5-2----•---........... 1�lons...�
Septic Tank — Liquid" capacity/�_�_�gallons Length___ ...�____ Width__V_"��_ Diameter________________ Depth__ 'rte
Disposal Trench — No ..................... Width ................ _... Total Length .................... Total leaching area .................... ft.
/� 1 6
Seepage Pit No ........... I...... Diameter_________ __ ___ Depth below inlet.___........... Total leaching area ._ __.�_ esq. ft.
Other Distribution box 0-4:1 Dosing t ( _
Percolation Test Results Performed by__1_1T...���•�i'•`� . Date ....... ....................
Test Pit No. !_____minutes per inch Depth of Test Pit ... ... Depth to ground water ...
•
Test Pit No. 2:4;;L:Z!n
___minutes per inch Depth of Test Pit..&__z. ...... Depth to ground water_. .46..Z.111
-•---•----•---•----------------------------------------------------•......._--------- --- ------ . ..... :._.
Cep -,32 a /C 3 /�a��.n ".02-5a...
Description of Soil Vii%_:.. ---}---
----------------
.0= Y 1
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 ' sued by the board of health.
Signed C------------------•--•--• ;/ �s.....
Da e
Application Approved By .. .` ...... .. ............... --.....---.....
Date
Application Disapproved for the folloiving reasons: ........... /----------------------------------------------------------------------------------------.
---...-•-•----------•---......-•-•-------------------------------•------•---•------------------------•---.-------------...------....-•--•------------------•----------•--'•--•---•---•-•---•--__..
Date
Permit No ---- ..Gl'Gl
`�----•--•------------------------ Issued..--------..IP-3 ................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................................:........ OF ...... .r..........................................................................
Trrtifiratve of Toutpliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( J -or Repaired ( )
by....... -------==--------------•----•-•---=--=..............--------------•--•................ •------••-------•--------•--------------•---•-------------------------------•---•---......----------
Installer
at••---•=-----------•--------------------------•--------------- ------_------------------------------•-------•------------------------_------------------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ..................... .................•... dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NO R CO ED ASA GUARANTEE THAT THE
SYSTEM WILL FUNCTIONSATISFACTORY.
DATE ............... -!:._. � --- p
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