HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..................... OF..... .............................................
Applira tion for Disposal Works Tonotrnrtinn Famit
Application is hereby made for a Permit to Construct ()<) or Repair ( ) an Individual Sewage Disposal
�� System at : 7�VIJAWOU716
Location - ddress
- or Lo o.
w 1.caner Address
------------------------------------------
.................. ._...,
I Installer Address
Q Type of Building Size Lot.
j f !Z ®......Sq. feet
Dwelling —No. of Bedrooms............................_._._._........_Expansion Attic ( ) Garbage Grinder ( )
Other — T e of Building No. of persons ............................ Showers — Cafeteria
a Other fixtures ................................. .
W Design Flow ............................... S_4.�...gallons per person per day. Total daily flow ........................ 33.P ------- gallons.
WSeptic Tank — Liquid capacity/O2Qn.gallons Length.-(..... Width. :4Q__. Diameter ................ Depth4.........
x Disposal Trench — No ..................•-- Width.................... Total Length ....._.....` _....•_ Total leaching area .................... sq. ft.
Seepage Pit No ....... I............ Diameter..( ..•f:2._.. Depth below inlet .... 4_-_._.....•. Total leaching area.ZA!�--- sq. ft.
Z Other Distribution box ()<) Dosin tank )
'-' Percolation Test Results Performed b3 ......
Test Pit No..__(Z minutes er inch Depth of Test Pit._ O." Depth to ground water.._ P..Q
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
P4---------------------------------------•------------------................----••------------------.----------•------•-•----------------------•---------•--
O Description of Soil L Ni..!�Mb......i mff---`r!%. d.....gAfg4E!-- ---------------------
xfJ �� .� O/4 • J4N'4---A'u 01.4------------------------------------------------------ -------------------
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VNature of Repairs or Alterations — Answer when applicable..............____....-.:___-_..__.-..............-..............-------....._--._....._....._..
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T IT L; 5 of the State Sanitary Code — T dersigned furtl r agrees not to place the system in
operation until a Certificate of Compliance has been issu"Yta�rhea
-•-•••-•--•...--------•--•---•------•.......
r.
Application Approved B
Zat_� --------------- - Z-�7
PP PP Y
Date
Application Disapproved for the following reasons--------------------•-----_---•----_•_--_--__-•--_-.---•--__--•----_--•_-
.------------------------------------------------------------------------------------------•-••----•--------•••••----•---••••-•-----•••-•-------••----••--•--•••--••--•.••.
Date
PermitNo --------------------------------------------------------- Issued .................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..............'� .............. OF.............................
..................................................................
At
wr#ifiratr of Tamplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( :) or Repaired ( )
bY........... ---------_-------------..- ... PIP!-------------------•--------------•-----•---•-••-------•-------.........•---•---------•-----•----•---•--................---•------------...._
x`� �n Y
at L �'G lc ip %r l :. �.:.. �.7 o Installer
w - ------•----------------------------------
has been installed in accordance with the provisions of TIT 1F 5 of The State Sanitary as_described in the
application for Disposal Works Construction Permit No----- --- ---------------*..._....... dated__.':L_ __`!..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................................................................... Inspector