HomeMy WebLinkAboutApp-Permit-ComplianceT f-kj- ,j 1! U U S .nG't� _,� tL 4 r l Li C,r I
South. Yuri; c)uih' Nvt 0,x, 64 Fps. Zc�........_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
1.....
................ OF ...............
%I
Appliration for liapnoal Works Tonstrnrnun "prrmi#
Application is hereby made for a Permit to Construct (D) or Repair ( ) an Individual Sewage Disposal
System a
Locat•on _ Address or Lot No. �--
---..4.....,-------------------------------------------------••-------------•-•-•----•-------•-•----•..
---..........._............................. Owner Address
In---st--alle----r -... ----------------------------------- ------------------------------ ---------...._..-•ress--•-•----------------- ------- •........ Add--
Type of Building Size Lot ....% . ...... ---
_....Sq. feet
►-� Dwelling—No. of Bedrooms ___.......-'_____________________________Expansion Attic ( ) Garbage Grinder ( )
aOther — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Other fixtures ------------••-----------•-•----•- _
W Design Flow ..._....... �..... ..................gallons per person per day. Total daily flow ................'...._............_._._gallons.
WSeptic Tank—Liquid ca.pacity6??=?gallons Length ___.__. a:. Width .... 4._`_.... Diameter________________ Depth ....'..___..
x Disposal Trench — No. ...... ./__........... Width____ ________ Total Length.....:�:..... Total leaching
Seepage Pit No._._.__°&.......... Diameter .................... Depth below inlet .................... Total leaching area .................. Sq. ft.
Z Other Distribution box ( pi' Dosing tank ( )
`-.' Percolation Test Results ' Performed by.__. ._. _. Ij eL-� _.`! C.�__. Date ... _ ._ 30 " &�
a_---------•-------
Test Pit No. 1__ ____minutes per inch Depth of Test Pit.__i_.N.. Depth to ground water._.f.%.f__y...._..
44 Test Pit No. 2 ................ minutes per inch Depth of Test Pit -------------------- Depth to ground water ........................
---------------•------------••----•--•-----------------------
-------
••--•-------•--------•----•-------
•---------•---_.
Descriptionof Soil.._•------ `5�— .._..-------•---...----•----•.......................................................•---------.....-----------..
...............•---...------------------------------•-------------------------.._.....-----------........--------...-•-----------------------...._....-----•--------------...--••-----•--•--•---------•-•
---•--------------------------------------•------------------------•---•-----------....----------------._.....----------------------......-•------------•--------....------•-----•--....---•-•---------
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 TITIN 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 board of health.
Signed......... -------------------------•-•-•---------- �...41...a�f'....._....
Application Approved By ... G?1, .-a./� J�--............................................... - - . J-?�.------------
Date
Application Disapproved for the following reasons-------------------------•-----•-•--------•------...........---•---------------------------...--•----•-----......
--------------------------------------------------------------- ........................................
Date.
DS' 2 (� 2.i ��
Permit No-------------•-- D5—Z2 Issued.------------------�-----•----•--•------------••--•----
Date
THE COMMONWEALTH OF MASSACHUSETTS
�Q% 5 BOARD OF HEALTH
C....... ....... ....._.....OF..... ................................................................................
Et a ifirtttr laf Toutplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (t or Repaired ( )
by.. •.. ...:.........•----....------•---------------•-•---- •-----•- ------•-•----....:_...---.::.........---------- •---------•---------•--
,�J Installer
at. i l iarx+.:..!...: - - ---- ___ ---------
has been installed in accordance with the provisions of TIT UP 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No. .e�' _--aa ............... dated___ Uq12J__t_16_x-`__.......................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEMA WILL FUNCTION SATISFACTORY.
DATE................................................_ Inspector.--------------------------