HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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'0Ut�)c Appliration for Diiipwittl Midw Towitrurtinrt Vinutit
Application is hereby made for a Permit to Construct (L,/
) or Repair ( ) an Individual Sewage Disposal
C, System at:
1 Qt9.X.---............:....l u..:....Y/.R15.A.&W. fy----..... .......„Y&AV - --.... V .........
Location - Address or Lot NOT.
UNature 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 TITi I', 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.
Application Approved By... ............... . C ,..G_.'
Application Disapproved for the following reasons:
Permit N
Date
'.7. ---------
Datc
Dam
Issued......................................----------------
Dam
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Trrtifirau of Tompliattrte
FY, That the
constructed (,,) or Repaired ( )
hasbeeninstalled in accordance with the provisions of TIT F 5 of The State Sanitary de as descrfb m the
application for Disposal Works Construction Per No ..... ...p dated... .....:..�... - -.
....... ....
THE ISSUANCE OF THIS CERTIFICATE Slat LL NOT BE CONS UE®�S GUARANTEE THAT THE
SYSTEM WILL. U TIO SATISFACTORY.
DATE..............- ��d............ _-_--------.-- Inspector-- l..e(`' . ................... - ................
...................................
..... /3 Ow;r _ / ,
Address
w
a
--....
D,smt�er
Type of Building
---- ....
Address
Size Lot ............................Sq. feet
U
Dwelling—No. of Bedrooms.. ........... ........ ___ .... _-Expansion Attic
( ) Garbage Grinder We,)
WOther—Type
of Building ..N✓.:A.............. No. of persons_ ..... ............. .......
Showers ( ) — Cafeteria ( )
P.
Other fixtures .................................
Design Flow..-..----- /..C?....... ---........... gallons per w per day. Total daily
flow .......... ............................. gallons.
W
W
Fi
Septic Tank — Liquid capacity./.op°_gallons LengthSe.: A.".. Width ''Ift..... Diameter ............... Depth..5....8....
Disposal Trench —No ..................... Width .... ............... Total Length ..................
. Total leaching area ............_......sq. ft.
Seepage Pit No ....... ✓------ .... Diameter..... 8---°------ Depth below inlet... -.C2 .............
Total leaching area.., ..Q..O...sq. ft.
Other Distribution box (� Dosing tank ( )
Percolation Test Results Performed.......C:d.,eF .0(,.6 ... R s.Date..... t. 4.1!.d::A....L.��./..%.?.�j
lj
Test Pit No. 1..4.. ....minutes per inch Depth of Test Pit ..41 ... ........
Depth to ground water_At.O-N.A9........
(x,
Test Pit No. 2................minutes per inch Depth of Test Pit..............--....
Depth to ground water ----- ............... ....
P4..................................
................... ......--....................................
-..............••......................................
O
Description of Soil_.. 0.-- ... V,..*....G.O.Arl...... A -W -b ......... r l f'3. +.P.�.L:---_
------------ - ....................--.....
U
- .LLt.M......... 54rj..0..... - ...-......................................
..... e^2. `c z
- ........ .......
W1.............................
--•........... ............_..--........-.....l.L.,
......ao..-----leaA __, &.........f"tvc.)-,VA.:rA6r2�.0........................-----------
...........
UNature 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 TITi I', 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.
Application Approved By... ............... . C ,..G_.'
Application Disapproved for the following reasons:
Permit N
Date
'.7. ---------
Datc
Dam
Issued......................................----------------
Dam
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Trrtifirau of Tompliattrte
FY, That the
constructed (,,) or Repaired ( )
hasbeeninstalled in accordance with the provisions of TIT F 5 of The State Sanitary de as descrfb m the
application for Disposal Works Construction Per No ..... ...p dated... .....:..�... - -.
....... ....
THE ISSUANCE OF THIS CERTIFICATE Slat LL NOT BE CONS UE®�S GUARANTEE THAT THE
SYSTEM WILL. U TIO SATISFACTORY.
DATE..............- ��d............ _-_--------.-- Inspector-- l..e(`' . ................... - ................