HomeMy WebLinkAboutApp-Permit-ComplianceNo....... �..._�...�
1 ` THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.....---------.............................oF..�-�'�.► .................................
Appliration for 31ispnsttl lVarks Tonst mfion rrrmi#
Application is hereby made for a Permit to Construct
System at: C,
Com• -
~ --°`tion ddress --
..---N ..11'l.�... S ..-- •------------------------------
- _ .Owner
...... ....`-....0 .V .. ..........................................
Installer i-1
Type of Building
Dwelling —No. of Bed
Other — Type of Build
Other fixtures
or Repair (� Individual Sewage Disposal
or Lot No.
..
....................................
Z.11�?Address
2+!lc
..........................................................
Address
Size Lot ............................ Sq. feet
...................Expansion Attic ( ) Garbage Grinder ( )
No. of persons ............................ Showers ( ) — Cafeteria ( )
----•--•--••--•---• -•-•--•----•......--•-•-------......-------•------------------•----------------•----•--•----•••--•-•--•--•--•-•--......---•----
Design Flow •...................................... gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid' ca. city ....... ... ]ions Length ---------------- Width ................ Diameter ................ Depth ................
Disposal Trench — No .................. Wi h .................... Total Length .................... Total leaching area -------------------- sq. ft.
Seepage Pit No.-_ ........ ...... Dia eter ..... .............. Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box ) osing tank ( )
Percolation Test Results rformed 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 ........................
Descriptionof Soil ........................................................................................................................................................................
........................................................................................................................................................................................................
Nature of Repairs or Alte tions — A saver when applicable%efT/..�-.�J_�_1_!✓...............................................
-----------------------------._-.. !til 1P- L��t13��1d'� `_�.... ! ^�//...!� ..----------
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 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 b the and of health.
Sign�`'-------------------------------------------•----------------- ---- I3." _....
Application Approved By----------•-----•--------------•---------•---•--........---....----•....---•--/tle�
----- -� '/�
Application Disapproved for the fol wing reasons------------------------------------------------------------------------------------------------••....-••-•......
D te
Permit No. .C. 6
...................... -- Issued.---__------•-- /
Date
THE COMMONWEALTH OF MASSACHUSETTS
t
OARD OF HEALTH
......... ,L v ....................... O F. L/. Q I� 7v............................................
(ffrrtifirab of Tompham
THIS IS TO CE� FY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by -------•----------------- -1.
-•---. -` U/�-----_�............--•------- - .-----------------••-----•--..........---•------•-..............------. .........-- -----
` jw0� -
Installer
!.t el.Azl
has been installed in accordance with the provisions of TITLP 5 of The State Sanitary Code as described,in the
application for Disposal Works Construction Permit No --------- x,1-.0.' 5E ....... dated ........ ........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS: A GUARANTEE THAT THE
SYSTEM WILL /FUNCTtON SATISFACTORY.
DATE............. .......... Inspector...... ,. :. ...........................................................