HomeMy WebLinkAboutApp-Permit-ComplianceNo. ��.�!..... .. Fxs...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
C3GtQlt(...
...... OF ..... I`�F10�--------------------------------------
Appliration for Dispntial Wor .rrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: {� q/t. V�
to -r 27
........................ ....... --•-'Ir - •-
oca ion - ddr
..........•• -• — - .�....�l G. ... _... ...[__..._.. �5. ...... ........: L_ -_Q Address
.................................
Citi% '%'
Owned ress
---------- 1.c = •-------- .....--••-•-----------•--•-•--•--•--------------•........................-
Installer Address J01- �9 -
Type of Building Size Lot.................Sq. feet
Dwelling — No. of Bedrooms ------- 2 __.. ................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures --•-•-------------•------•---------•--------------•---......-----•-----------------------••--•-------------...-----.....--------•.....••----.....-----
Design Flow ......... :----.---_---.-___---6.-r..gallons per person der day. Total daily flow ........................... ...gallons.
Septic Tank — Liqu>d capacity/00.gallons Length _'-4..•-. Width.'I-_I4 -. Diameter ................ Depth..-� .4'..
.Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .... __..____.._.._sq. ft.
Seepage Pit No ...... 1 ............. Diameter.Ce_'*. �..... Depth below inlet .... ��'........... Total leaching area. ��.-r-....sq. ft.
Other Distribution box (K) Dosin�ta� (�) 'i�� 2� 197x7
Percolation Test Results Performed by-_ -t. _..__......... ._ Date.....__....__..._ ._
J ------------
Test Pit No. ILEI 2minutes per inch Depth of Test Pit -__—/ 2 `!__.. Depth to ground water.!A//?...
Test Pit No. 2 ---------------- minutes per inch Depth of Test Pit .................... Depth to ground water ........................
-------------------------------••-•--------•----------.....-----------.......---•-------•-------------------------•-----------------------•-••------------••.
Description of S
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 TIT?.;. 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------------------------------------------
Application Approved By -----
Phe 1 h Officer
Application Disapproved for he ollowing reasons- -------------------------------,
..........................................
...........
Date
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Date
PermitNo --------------------------------------------------------- Issued --------------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................................. OF .....................................................................................
Grfifirat a of Tomplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by-----------------------------------------------------------------------------------------------------
Installer
at---------------------------------------•------•----------•-------------------------------------------- -----------•--•--------------------•---------------.....----•-----------------------------------
has been installed in accordance with the provisions of TITLEc ` of The State SanitaryCo . as scribed in the
application_ for Disposal Works Construction Permit No ---- d_-�............... dated_._.lU _..___..:.............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® ASA ARANTEE THAT THE
SYSTEM WILL FUN TION SATISFACTORY. {� j
DATE.................. 1............ '.....--•-•• ......................... inspector ........................ '.............................. : ? s ---•-.