HomeMy WebLinkAboutApp-Permit-ComplianceFxs...... —C -'_ .—
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..--\.e Wn............... OF .... .VP-I,1`-!1!'!gA..............................................................
Appliration for 11isputittl 18orks Tons rurtiun rerun#
Application is hereby made for a Permit to Construct ( ) or Repair () an Individual Sewage Disposal
system
at:
�tr��e�..rlut---4�:__ attt±t�tu►........ .........--..'-.�!��. ......YYI_.: 1s....--.
Lion - Address or Lot No.b
----------- •----------------------•--•-- -------
ala_. u� �,�r�ac�.....-----------
pp.n� ddres -'
.. ...................•----------••••-----....._--------------•...._.. _315_a__ .... &rn..`
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling — No. of Bedrooms -------------------------------------------- Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures-----------------------------•-•----•---------•-------.---------------•----------•-•-------•-•-•--•---_..._.......---•--•-•----......----•- •---•----
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 ........................
Descriptionof Soil ----------------------------------------------------------------------------------------
-----------------•---------------..........--•------•-----------•-----------.._.........-------•---------------------------.....----------•---•------•------------_...% ---.......................
.................v.... .
ature ofepairs or Alteratigns - Answer when applicable_ �i_a_4�,r.u�c___(.o.D9___S,�Z e. AWlsk., -..:_..__.
Wb. G2nr -1 : eno, me. hQ.G.ULt - ---------- ----------------------•--------
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLZ 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./ .....
Application Approved By .......
Application Disapproved for the
PermitNo._.�-........................... __.._
:!6
� a'
Datee
.....................................
.........................................................................
-
/ff Date
Issued C---- - ------
.�-1 .�........_
THE COMMONWEALTH OF MASSACHUSETTS
2
BOARD OF HEALTH �1 ll (r
... . .................OF. ��r...r.!r!fG.la`th................................ ............
Ta ifirtttr of fa-amplianrr
_THIS U TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (4 )
by -It ...•••-•••---- •-•--•-••--...••••.._.....---••------•-.....•-•- •••-• _._..
Installer
at_..Ifi!?e!-+�c�Q_.4.1�..�'�t/E.����1.��2(��a�?:!-1 ----•- ------ -.------------------------------------ ----- •-----• •------- ------
has been installed in accordance with the provisions of TITLE of The State ode a Sanitary r} a c the
application for Disposal Works Construction Permit No.._f2__C1TL _. _. dated . ..,_.� �j-l_•u---•----•-
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A G AttKIR7EE THAT THE
SYSTEMA ILL FLINOTION SATISFACTORY L
Inspectq�-
- 2a ............... .......-•-•--- l' '' .� 1 �- �'(= ? --•--