HomeMy WebLinkAboutApp-Permit-Compliancea +" b C ®�� See- � �
3 /1 Z14N `�lvyoc.r9-y
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7.W�V ...............OF............ � ® -l1 ........
Appliration for Rap o sal Works Tonstrnrtion rnmit
Application is hereby made for a Permit to Construct (I)' or Repair ( ) an Individual Sewage Disposal
Systema � Grli T 20 47-.'&
Locat' Address or Lot No.
.. .. 06-R.
6 &-bgy'Ll.
Insta ler1
� r w Address
Type of Building Size Lot..>.�_------ Sq. feet
Dwelling —No. of Bedrooms .......... .............................Expansion Attic ( ) Garbage Grinder ( )
pa, Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ----------------------------•--• -
_
3 C7
W Design Flow ------------ ��...................... gallons per person per day. Total daily flow .-.-...-•-•--.�--.._._.___.___gallons.
WSeptic Tank —Liquid capacity.6P!Q9.gallons Length..9_®G .... Width. .K..... Diameter ................ Depth. � .....
x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ......... ......... Diameter ...... -1 __.... Depth below inlet ..._........... Total leaching area ---2i7 ...sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by. %Y P.. ...... ........ . C S! o T Date...i7 /-V,0
a Test Pit No. 1 --- #&-Z..minutes per inch Depth of Test Pit........ _-_. Depth to ground water .....�..�.._..........
f� Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water...---..................
----l-!-----••-•----------•-------------•------------------------------------ .........................................................
..0Description of Soil-•---3�"'0..... .3 -................... . _`41...
-----.......�..:...- ......._.. /'moi` = ��'�`�`�'� '�'
----••----------------------•-•-••-••--•-----------------------------------•----•••--••...-------------•---•--•-•--••...••••---•-•-•-•---•-----•---------•-------•-----••••---•-•--•-••-•-•---------•--•
Nature 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 TITiL 5 of the State Sanitary Code — The ndersigned further agrees not to place the system in
operation until a Certificate of Compliance ha bee s b e bo d of health.
Sign----- -- --- x------•-•------•---...-• .......... ......�.--(-l.._.p..- •.--.-._--....
Application Approved By. .��
Dae
Application Disapproved for the fol ing reasons:-•------------------------------------------------------------•--•------------------------------------....•-----
.-------------•............... ................................................. -................................................... .............................................
� Date
Permit No......... ----•-•-------------- Issued------•-•--•tlz /... at -------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
lit//V.........OF..............lJ...(J%7�
..............................
Trrfifirtttr of Toutp'liatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (L,,�r`or Repaired ( )
by....................................................................................................................................................................................................
Installer
at....................................................................................... ------••-•----•-----•---•----------•••---•-•----------•----•------•-------•------------------------•----------
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 SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......................•-•-.....-•----......--------•--....-------••--------•--- Inspector ....................................................................................