HomeMy WebLinkAboutApp-Permit-Compliance`No.7-5:�d7
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THE COMMONWEALTH OF MASSACHUSETTS
OARD OF HEALTH
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Appliration for Disposal Works Tonotrurtion Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair (4 an Individual Sewage Disposal
System at:
LocAionn
.._.Addressor Lot No.
........_.............4 .. .4.v_ —0�C.....................•^.............................
Owner Address
.,...... T---•-----•------------------------•-.---.---••-•----•.......------------•.--•-..._........_...............--•------•--••---•......-----------...
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 ( )
PercolationTest Results 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 ........................
Descriptionof Soil ........................................................................................................ -.................. - ............
.-•------•-------------•--•----.....--•-----•------------------•-----------•--•----••---•--•------------•-•----------------•-------------------------- ..................
Nature of Repairs or Alterations — Answer when applicable.._ f'__..1D �d ....�� . �.._ .__/r�"� ..._..._
-----=------------------------------------------------------------------------------•----------------- s -----------------�-------------------------......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1 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.
5igned ...................................................................................... ./''
...... - ...
�l�_ I ' Date
Application Approved BY "�./( .. �.._....--------
11
D e
Application Disapproved for the a0ho'biAffkffs----------------------------•------------------------•---------•----------------------------------------------•--
..............................•-------......-•----------------------------------------------------------.-----------.....----------------------------------------------------------------------•--•-•--.
Date
PermitNo --------------------------------------------------------- Issued ---•---------------•---------------------------------.._
Date
THE COMMONWEALTH OF MASSACHUSETTS
/BOARD OF HEALTH
............%..... C�G� ...... 0 F..... ..: r' ...... ...............................
At
Tntifira of Tompliaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (i
bY............
------'-'=-f ............. /_ C._ . t/_ ................................... -------•---•------------------------•---•---------•------------------------.....--•-----------------
_ y Installer
at..... ......... /---......--sem......................--------------------------------- ------....-----•-•....----••---...------..._..---------------
has been installed in accordance with the provisions of TIT F,-,--5 Qf T State Sanitary Co�d� s des ib d_.in the
application for Disposal Works Construction Permit No.___J� :_�-�Q ......... dated -__..___! ._1.T1Z.z ..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A G ARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector