HomeMy WebLinkAboutApp-Permit-ComplianceNo .... FRZ../65.. ............. .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................... ..................O F
Appliration for Dispaoul Worko Toustrurtion JIrrutit
Application is hereby made for a Permit to Construct (A) or Repair an Individual Sewage Disposal
System at:
. . ......... -4)
..... . ...... Rdit ............................. .... ............................... q.1 SA
ion _r or Lot
- _(M � S A -A4. I
'es '2 ..................
............ ---- L. 4
o- -
Address
....... ............................. ---&Z
Installer
_Xte.-----------------------------
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms.._.___ .. _,1 ........................... Expansion Attic Garbage Grinder
Other—Type of Building ............................ No. of persons__...____._...._.....__...__ Showers Cafeteria
OtherfiUures......................................................................................................................................................
Design Flow._.__ . _5._Z5 ...........................gallons per person er day. Total daily flow ...... ------ ---------- --..--gallons.
Septic Tank — Liquid'capacit*.!29P.gallons Lengthy'_.�.... Width..� ..... Diameter ................ Depth ................
Disposal Trench — No ..................... Width .................... Total Length_............__..... Total leaching area .................... sq. ft.
Seepage Pit No.._.-_ZI ............. Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft,
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by .......................................................................... Date- ......................................
Test Pit No. I ................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 ........................
................... ................................................................................ .........................................................
0 Description of Soil ................................................................................................. ............................................... ......................
W
U.................................................................................................................................................................................. .......................
..................................... .........................................................................................................................................
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 ed f health.
Signed---•• .. ........... ---- --- .............................. ......
Date
ApplicationApproved By. . .. ... ..... ... .......... ...... . .. . .... ................................ ........................................
Date
Application Disapproved for the foll wing reasons: ........... ....................................................................................................
..................................................................................................................................................................................
Date
Permit No .......... 2 2
.............................................. Issued.- - 2S~ __ .......................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................... .......... .............................................
Tntifiratr of Tampluturr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (4"Or Repaired
by......... ............................................................................................................. 1� ..............................
Installer
at........
r....... e_
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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 ------ ............... t ' - - J_ >Z'
----- dated__! .......................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. ) -
C 4�_
DATE. ............................................... Inspector—'C-1 ... ............
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