HomeMy WebLinkAboutApp-Permit-ComplianceINSPECTION DATE/TIME: M/P #
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No.�.Z-�� Fss..��Q...........�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH'
.........TOWN..................OF...............Y: J
--- --------------•---•-...--•-----•---
Appliration for Disposal Warks Tonstrur#iun 1hrmi#
Application is hereby made for a Permit to Construct
•System at: I i
.............
••--
... iznL ... E ....... ".11ak,
ocati • n -Address
` 'caner _
........... ,..� •�-- =. ...
- •CMZ'j.-' .t sk �--------••------------
Installer
) or Upgrade ( 4-- -airindividual Sewage Disposal
- or Lot No. ................................
�c r.
- , A ress
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 ( )
Otherfixtu es --•--•-••-•---•-••-------------•-••---••••••--•••-•--••--•---•••---•-••-----•-•-----------••-••------••--•--
Design Flow ............ S. ______________________gallons per person pier day. Total dail Pow.......... 3_ �0� ................... gallons.
. ! :mac: u l
Septic Tank — Liquld cap ty..�__...:.gallons Length/_C L...._._ Width_'a_._ _...... 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 (--I' Dosi tank( )
Percolation Test ResultsPerformed by.�, a._IC.�''�__..__%__ _________________ Date ........................................
Test Pit No. I .... L.:A:i'minutes per inch Depth of Test Pit ...... Depth to groundwater..,/) �...
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
------------------------------------------• •------•--------.._ _... _..............-------•----...._...........----•--•------------------••••---•--------••-•--
Description of Soil ............. ^�..............i-) ----
................................T .Y �....y►.......1C_k:1f_.......______.__._______________._...._......___....____....__._......_________......................_..._...___
...........................................................•-------...I.............................._._................__.._...._......._.._....._...................._.................................
Nature of 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 Environmental Code — The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued b t board of health.
0
Signe .....' ,,•a, C� --... i ------- {
----------- -- Dat "--'------
t pplication Approved BY ------------ ---------------------------- ------ - -� t
Date
!'application Disapproved for the fo lowing reasons: ..
G ---------------------------
-
Permit No. ------.. o--•--/---te
-------46 ------------------------------ Issued ------------. ----.l --naate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH -
---------TOWN OF .. �' �K:
Cgerttftxtt#e C�ax> cit�xxtce
THS IS TO CE TIFY h the In Sewage Disposal System constructed ( ) or upgraded
by---------- ------ In . stall----er ------------------------------------------------
,� �j
has been installed in accordance with the provisions of TITLE 5 of -The Statq Environmental Code as described in
the application for Disposal Works Construction Permit No. _----:-1'Z-------------- dated ------ �ffdPi..-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------------------------------------r------------------------------------------------------------------ Ins ector ----- --
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF .............. of
..........:................. FEE.. ..
No... ..•-• r� (J 5..�........
iixaatl rk ��rn ' n anti 44
1'
Permission is hereby granted.------. .�_.... ..SFJ ..................................................
to Construct ( ) r Up ade (,,�an'Individual S�ewaa Disposal System
atNo ................ -dk�- - ......... W_&.�--t--•---•----
Street
as shown on the application for Disposal Works Construction Perm;j .__ _ ��
_ Dated------- . .....................
--
•". ____..%....-.l ................ .._ ........ __......
... _•
Board of Health
r....... --••-•--
Revised 7.20.94 �'.`