HomeMy WebLinkAboutApp-Permit-ComplianceNo. g7 Z.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH-
�� A.h
------------ OF......... :4..j ,2? .........
Appliratiun for 11ispnsal Works Tons#rnrtinn Fnrnti#
Application is hereby made for a Permit to Construct ( ) or Repair ( �i Individual Sewage Disposal
System at: L
............��»»»_..........................•-• --.......-G=�.l!s: »...» ».........»..__-- ..
Location - Address or Lot •No.
...............i ...... v�K:..--•-•-•----•....----•-........_..... ..................... ... ....... ..............................» ..
..... ........1�...C�
Address
/. •---•---......._^__...•.. ........... �l-..-
................••••.....
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms-_ 2....................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures------------------------------------------------------.....--------...-----------------------------.-..........-----------..........----•-------------
Design Flow......... ................. gallons per person per day. Total daily flow ....... 23_ .C�........--..........gallons.
Septic Tank —Liquid capacityi.(M...gallons Length ...... ......... Width... S'._.._._ Diameter ................ Depth ................
Disposal Trench — No . .................... Width .................... Total Length .............. 7.... Total leaching area ................... sq. ft.
Seepage Pit No ..... j .............. Diameter ..... LD-_.___. Depth below inlet .....:4......... 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 ........................
Descriptionof Soil ........................................................................................................................................................................
.......................................................................................
Nature of Repairs or Alterations - Answer when
Agreement: .1
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 boarHe _ n
�. - ... .
ID
Application Approved B Phee
..... �_ . % . .1.... --
PP PP Y ...- ......._.._ ate
Application Disapproved for ll 'ng reasons----------------•.......------------•-•---...........-----....•..........------......----•-......---....---..»..
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Permit No. V1..–.1...1------------•---•------------------.—
THE COMMONWEALTH OF MASSACHUSETTS
? 198'1
9 8' ,`(7
Date
.... -•-.............»....
Daft...
BOARD OF HEALTH
........ : 5 :4: ' ........OF......` Gt..� .Y.!:. ....................................
(Inr#if iratr of fauntphitnrn
THIS IS TO CER -=I -F _,,That,the Individual Sewage Disposal System constructed ( ) or Repaired ( E
by............................................ �.........r s-. .:.r.........:11-- e._t1............------....•.............------..........---............_........_
Installer
at. ....------•••..................................... ', .: .....---- ... 1.:y ! - \\ f - ..... - ....... .......
has been installed in accordance with the provisions of TIT F of The State Sanitary �ode�e described in the
application for Disposal Works Construction Permit No..`5 7 ...................•. dated__. tx I9�7
PP P ........ t
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A l UAR NTEE THAT THE
SYSTEM WILL �F!V CTS NN SATISFACTORY. �'�r� /
DATB�� 2� err �4
y..............�---------..-----.------------------- Inspector �........ '....... - .., �? ..�...................