HomeMy WebLinkAboutApp-Permit-ComplianceNo -,P3::Z2.1 Fis........ 2r..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
bC i\I......... OF.............`.I.T.T. J --..._.._ ...
Appliration for Uispoottl Works Tontrnrtion 1hrmit
Application is hereby made for a Permit to Construct G l or Repair ( ) an Individual Sewage Disposal
-443 S stem at* J 6� /Z
Location - Address - or Lot No.
... - ---------
Ow r Address
aPQ A
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Installer Address �p �.
Type of Building Size Lot -e STI_ 7 !Sq. feet
U Dwelling —No. of Bedrooms.............................................Expansion Attic ( ) Garbage Grinder ( )
Other — T e of Building ............................ No. of persons ............................ Showers — Cafeteria
P4 Other fixtures ................................ �
W Design Flow ............ .................... gallons pe`r' per day. Total daisy flow-•----.... :.. _._ ._._..._.... dons.
WSeptic Tank —Liquid* capac>tyl.C)Qallons Length..6:- 62..�Width..r-i_ /K- Diameter ................ Depth. .
x Disposal Trench — No .
...........:......... Width..___......_._..._ Total Length._....._.._ _...--. Total leaching area .................... sq. ft.
Seepage Pit No .......... I ......... Diameter ...... ko..... Depth below inl...... Total leaching areac,6d7 --- sq. ft.
Z Other Distribution box (N' Dosing tank ( ) � Q,�a'
'-' Percolation Test Results 2 Performed by.._._ -__-..4.L,�_d... /��yv�._l A.C. Date..... __-. �.I ..._ .
Test Pit No. 1_ _....._.minutes per inch Depth of Test Pit....Depth to ground water .___."'...—"'-...
fs, Test Pit No. 2.........Z -minutes per inch Depth of Test Pit --- ----Depth to ground water -__`--`.�---
U
Description of Soil. ------. d- ►.._.. 111 �, � ` �Q % ------•-------------
U?...-.. j� Y•-Sj4n�b �JSt/)T Z .- ✓��z N0,1CA-P�-i-----C ?�J5u7T 3L��
�-•--•--100
lk-� 1- "------ P • r.) A)f �AD
UNature of Repairs or Alterations — Answer when applicable .............___._._._._....._.._.__.._ a..__._Z ..._._._.._.._.._....._..
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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 bee 'ssu the rd of h
Signed_ . ------------------- -------..........................
Date
APPlication Approved By..,i! r,�`---------•---•................ •--•-•-•--•-. ---- `�
------•.................................. Date
Application Disapproved for the folio ang reasons_ .............. __________________________________ .___..________
..............•--•--•--------•-•--..........-•--•--•-"---------------------•--------------......------....---------...-:..-----------------•-----•------------------------•-----..............-----------
Date
Permit No ...... :LL- Issued_`�
...............................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
T..7rrz/........ O F.�sr���%................................
Trrtifirtt#.r of Tontlrliatty
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( )
b--------------------------------------- -------------------------------------------------j....-----•--------...---•--------•--..._....-•-•-----••---------•••-.
Installer
at.... a. --------- a--�------------------------------
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._s� _=Zj/-..................... -_"_--_. -.------_--------.-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE--------------------------------------------•---....---....---------•-----•-- Inspects .... ---