HomeMy WebLinkAboutApp-Permit-ComplianceNo� 7 J Fxs......! s .........._....
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH HEALTH
`/���5)...-........OF...............7l i iLi(�9
Appliratiun for Diipusal Works Tonsiru tion rrrmit
Application is hereby made for a Permit to Construct
System at:
......
Location - Address
/ 1 :........................
..._.
----- - --• ----- -.... Owner
Installer
Type of Building
Dwelling — No
Other — Type
) or Repair (1)Q an Individual Sewage Disposal
--------------------------••--•---------•------•---------------..............--------.............
or Lot No.
dress
Address
e� Size Lot.-. 410....._.So. feet
of Bedrooms ................ ..................Expansion Attic ( ) Garbage Grinder ( )
of Building ............................ No. of persons........................--.. Showers ( ) — Cafeteria ( )
Otherfixtures..........•...---•------•---•-------------------------•--••------.......--•---•-•------------•--------•---•---....----.........-•••--............._...
Design Flow....................�-_----•--------gallons per person per day. Total daily flow ......... ....................... gallons.
Septic Tank— Liquid ca.pacity.,ldOOgallons Length_.�y `"Width... Diameter ................ Depth ................
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No—a---? 4 ._- Diameter... Depth below inlet .... f ..`.�_._. Total leaching area..................sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by .......................................................................... Date ........................................
Test Pit No. 1................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 ........................
It ...•-�..................�C ...............--�..................--•-•--•--................................1--'� .........................
Description of So'1--------d----------•'•----- ...,..,.rte--- ---- - ----------W...4'•-C /X ........
.._.•....... -. �........................................................--------------....------------. --- ----------------.......------...................-----------------
Nature of Repairs o„Alteratiol
---------------------------------•-------------•----------------------------....--•--••••--••-----
Agreement :j 6'� ✓.- / $'
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT 1L 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been wed by the boar health. A o
Application Approved By
Application Disapproved f
Permit No ....... le
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Tom................ OF ......... ...............................
(ffrriifirtt of T%mpliaurr
THIS IS TO CERTIFY, That the Individual Sewa ge I,� sposal S7stem constructed ( ) or Repaired
bY------------------ g__.... J - - Q -------------------------------------•• ....
at.__...--•..... `. ...•-•-------.:•'r_�' �..........I!:_G.Insalley.................-----------------
/ �Sa?ef- /rT?.�t0� C t�iC1.
-----___ ----- .... _ .._.._.....
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 ----------------------------------------- dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCT ON SATISFACTORY. -'r–
DATE ........................ .................................. .Inspector------
.................................................