HomeMy WebLinkAboutApp-Permit-ComplianceNo.. 7.. 3� F$s....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
744---------------------OFeWAP..O.$...----------------------........---------------.............
Appl ration for wisposal Works Tonstrurtion rami#
Application is hereby made for a Permit to Construct
System at
..Location -Ad ress
.....1 . N ._Al:.P _. . •-
-- ------------------------------------------
Owner
�Q----•---------.' .........................................
Installer
Type of Building
Dwelling — No
Other — Type
Other
) or Repair (4(.) an Individual Sewage Disposal
or Lot No.
.3s¢�llPki..�o�u- ....................
Address
Size Lot ............................ Sq. feet
. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
fixtures.------•---•------------------------------------------.................---•-------------.................--•-----•--.....--•--
Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid' capacity.._.____....gallons Length ---------------- Width ................ 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 ( ) 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 ........................
Description of
-------•.................................................•---------------------..........-•---•--•--•-•-------------------------•••-•••-...._.
Nature of Repairs or Alterations - Answe whe ap icable: Th ..................
. fr-: j'-LI,Gr:�•------------------------------------•- Z ,.--------------- -------
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 been issued by the board of health.
Signed.-----i-IDstX1PJx.'__�4� .•----------------------•-- F= �._.
Application Approved B ------------••--------••-•------------..........•--•--
Date
Application Disapproved for the fol owing�eeas2:---------------••-----.......--------....-----------•-•----------..........._.............----••----.....
Permit No. U � 3 V1----------------------------- - -
Iate
ssued' Y 1!"' ""'"� 1.. `_�6..1..... D...... .._
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HELALTH
f.Gu?ri....................OF..... .'-�a oa.. ��Y�
(arrfifirttft of (aomplittnrr
M,� IS, TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (,/, )
has been installed in accordance with the provisions of TI -Tr F 5,,��QQf The State Sanitary C de s Sde�•cr' e�j1� the
application for Disposal Works Construction Permit No.. O.1 !_W_ ................ dated... }- .td.l..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED NTEE THAT THE
SYSTEIN LL N TION SATISFACTORY.
DATE 1 l �g --.-- Inspecto ��.
_...... f - --- - - - -- ----- ...............