HomeMy WebLinkAboutApp-Permit-Compliance...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
v
�ca................ OF ............ j.A W.A. QJzA
Appliratiun for Disposal Works Tnnuvdiun f ami#
•---------------------------•-----.......-----• •--_.._.. _...---•-----------•V.._..----------...--•.._.......-•-------------•------....--•---------
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITITS 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
option until a Certificate of Com liance has been issued by the board of health 10
Si d_. A L,C�--�---••--•- •--------- --••--•--•---•---
Application A roved B --��° . .. ��� e9 /8,
Alication Disapproved or the following reasons: �_-_-•---
•---- •---• --------- •-------------------------------- -Date
PP PP f f • 9 ons- -------------------•----.._...------•- ---------•-----
..------•-•----••---•------�—--••-------------------------•-------•-----....--------•------------------•-----•-------------------- ----._..a---._....__..__.
.2� Q.� '
Permit No--------- ------------------------------------------ Issued- ................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
6 NO ........................... OF ..... yd)P 6P. T# .................................................
(9rdifiratr of Tontplittnrr
HIS IS TORTIFY That t4 Individual Sewage Disposal System constructed O<) or Repaired ( )
bliAl ,212y_..,0_AIaM LAO.( .. (XAPky ...................................................................................................................
Installer
at_k_Tlc�OC
�IESEi--Al
i__lES%.._Z_+P!t'1QkTfzr -
-----------•-------------------------•---•------..._-------••-
has been installed in accordance with the provisions of T 'T' C of The State Sanitaryde as eij
scri j
.application for Disposal Works Construction Permit Not-•---------- ....... datedC-E'
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY
DATE.....`.0�.�.: -.................................................... -------------------------------
Application is hereby made for a Permit to Construct �K_) or Repair
( ) an Individual Sewage Disposal
System at:
--- ......--' z :.......
. .....A.�,, �, ��...s......._._...
` •� TLocation� -pAddress
............i.:�ST......S.LJI:!! ---------------------------------------------------------•----.._._._.._...._.........---..._......__..................._.
or Lot No.
a
Own
C,e,9,usiereY....- er- ��................................
Address
- - - ---
Installer
Type of Building
-...............................................
Address
Size Lot__9..0,.G5.�. _'...... Sq. feet
�.
Dwelling —No. of Bedrooms ..........3.................................. Attic
( ) Garbage Grinder ( )
Other — TYPe of Building ............................ No. of persons_________________._..__..___ Showers Cafeteria
Pao
Otherfixtures------------•-----------------•---•------------•------.....-------------------.--..-•--------._........----.......•--_....
•.--(-- ---_)..
Design Flow ------------------ .-.................. gallons per person per day. Total daily
flow ........... . ___.....______. __._gallons.
WSeptic
Tank — Liquid capacityle2!2__gallons Length__6,!C,,_._._ Width._A__6...._
Diameter________________ Depth______!? __.
x
Disposal Trench — No . .................... Width .................... Total Length ....................
Total leaching area .................... sq. ft.
Seepage Pit No ......... Diameter .... IQ `..__..__. Depth below inlet___ ._....._._.
Total leaching area.2`RID
Z
Other Distribution box ( -�,q Dosing tank ( )
Percolation Test Results Performed by .... '. _._.!? C �?! ._ .�.......................... Date__ .'2 .............
a
Test Pit No. 1 _.. ___minutes per inch Depth of Test Pit .... ]_.........
Depth to ground water ... n!2rs r--.
f=,
Test Pit No. 2................minutes per inch Depth of Test Pit ....................
Depth to ground water ........................
a----------------------------------------------------------------------------------------------------
.........................................................
0
Description of Soil ........................................................................................................................................................................
W
U
W
---------•-------------------------------------- •--------------------------- -•-•-•------ •----------------------------------- -••------------------------------------------------
----•------------------
UNature
of Repairs or Alterations — Answer when applicable ...............................................................................................
•---------------------------•-----.......-----• •--_.._.. _...---•-----------•V.._..----------...--•.._.......-•-------------•------....--•---------
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITITS 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
option until a Certificate of Com liance has been issued by the board of health 10
Si d_. A L,C�--�---••--•- •--------- --••--•--•---•---
Application A roved B --��° . .. ��� e9 /8,
Alication Disapproved or the following reasons: �_-_-•---
•---- •---• --------- •-------------------------------- -Date
PP PP f f • 9 ons- -------------------•----.._...------•- ---------•-----
..------•-•----••---•------�—--••-------------------------•-------•-----....--------•------------------•-----•-------------------- ----._..a---._....__..__.
.2� Q.� '
Permit No--------- ------------------------------------------ Issued- ................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
6 NO ........................... OF ..... yd)P 6P. T# .................................................
(9rdifiratr of Tontplittnrr
HIS IS TORTIFY That t4 Individual Sewage Disposal System constructed O<) or Repaired ( )
bliAl ,212y_..,0_AIaM LAO.( .. (XAPky ...................................................................................................................
Installer
at_k_Tlc�OC
�IESEi--Al
i__lES%.._Z_+P!t'1QkTfzr -
-----------•-------------------------•---•------..._-------••-
has been installed in accordance with the provisions of T 'T' C of The State Sanitaryde as eij
scri j
.application for Disposal Works Construction Permit Not-•---------- ....... datedC-E'
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY
DATE.....`.0�.�.: -.................................................... -------------------------------