HomeMy WebLinkAboutApp-Permit-Compliance'Dual Yµ� ni-south, ,N"A 02-55A F�s...�A' .......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OFF HEALTH
�
--------.,1 c�J'��----.......OF.............. .a..fi.P. M. P U ..[- ..............................
Appliration for 131sp sal Works Tons#rnrtiun "anti#
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at LL - I
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Location - Address or LotNo.
...................._»..».---•--..........-----.......--•--------------•-----•---...-----...... --......-----------------------------------------------
Owner Address
Installer Address
Type of Building 1 3Size Lot- 2Z.Q----------Sq. feet
Dwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons---------------------_--_-- Showers ( ) — Cafeteria ( )
Otherfixtures-------------------------------------------•---•---•--•----------------- -•------•------.-----------------------•----------••------------------------
Design Flow .......... -J�--�`�...........................gallons per person per day. Total daily flow ........+ �� .....................gallons.
Septic Tank — Liquid' ca.pacityiP2 ggallons Length ...... fir...... Width.... ::.... Diameter ................ Depth. -.4 -.....
Disposal Trench — No. ..... /............ Width ... /10!:--------- Total Length ----- ..-Z-.?... Total leaching area_3.-�3_,4..sq-4t.6 PJig
Seepage Pit No ..................... Diameter.................... Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box 0< Dosing tank
Percolation Test Results Performed by .... Z,.4.... ....
Lt2_44.Agkg ---..1 .5;�.... Date ----
Test Pit No. l_. _._minutes per inch Depth of Test Pit... Depth to ground water./.LIJ:.! .....
Test Pit No. 2 ----------------minutes per inch Depth of Test Pit .................... Depth to ground water ........................
•-•---------- —------•-•-------- ......... -
Description of Soil.... --------------- .fad :�A...----------------------..........--------- .....- -• -----..._----------•----•-------------
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.--------------•---------•-----•-------.....----..._..-------------------------•------•-•----------•--------•--....---------.....--•-----._.....-----••----.......--•---------------.......------.._.....
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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 syste in
operation until a Certificate of Compliance has be 'sed"therd of health.
Signed........... --...-•-------------------•------•-••----•. ....� .... ?............
Applica:tion Approved By.....�nN.a7��r .- C�......................................•- ...... l.....� . t .._...
Date
Application Disapproved for the following reasons---------------------------------------------------------------------------------•---------........----..........
Date
Permit No.... S' .Z -------------------- --- Issued------ �S
Date
- - - ---- - - - --
g —,j THE COMMONWEALTH OF MASSACHUSETTS O �- f U
Iv
�\ BOARD OF HEALTH
(� �a dry` OF.
.............................................................................................................................
(Irrtifirtt#r laf T antplinurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( Yror Repaired ( )
by... ----••------•...............•-----....----•--••-------------...--------•-•------------•--•------•---------------•--------...............-•-•-----...-----....
Installer
at. �4 -- �1i �.� � (i�� ---� -.......... ......................................................................................................................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitaryo e as described in the
application for Disposal Works Construction Permit ............. dated_ --, 2A-_
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................................................................... Inspector