HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............. OF ...... �A.2X�.'..ll'.:J':..................................................
FES..../ � 0-U
Applirttfiou for %ripo,13ttl Worlm Tatutrnrtinn Vrrmit
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Application is hereby made for a Permit to Construct ( Repair ( ) an Individual Sewage Disposal
System at:
C?.�c� cc.•..........."......1/6r s !'...! 9 iL C� i � `� Z 3
r4'..%...5 -... ... ...
Location -Address -
or Lot No.
c?N...............................................................
Onncr Address
Cta..�n..r�orl....-----'-----
vstailer 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 ................................... - - ... ......... .........--........ -..................................
l�Criz u on•
Design Flow-....y/j_e........................._.gallons per peFean perkay. Total daily flow........... 3..]�.......... .gallons.
Septic Tank—Liquid capacit�v/o-?(292gallons Length_c ........ Width..F '..... Diameter ................ Depth..*,.....
Disposal Trench — No. /.................. Width_./.5'.......... Total Length......-../�:> . Total leaching area. /.'F._Ca
Seepage Pit No ..................... Diameter .................... Depth below inlet.................... Total leaching area .................. sq. ft.
Other Distribution box ( < Dosing tank ( )
Percolation Test Results Performed by....l ......... Date.. -1
/ :... v
Test Pit No. Lper er inch Depth of fest Pit ...2..... p a 4. DeIpth to group water.... -. .....
aS.
Test Pit No. 2....t ... minutes per inch De Depth of Test Pit .................... Depth to ground water...... Ze„ ,.`P....
Description of Soil. ..... ✓ <—fviz-.'........�.�c - � � fFcav2 � � v
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 :I P 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate o Compliance has be sued by t d of health.
Signed ... �-�..• ..... q 1
Application Approved B�
D.M.
Application Disapproveor tlae follo ai ng reasons: ....................... ---..........
Permit No... .... Ko, 7.............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Data
..............
.......................................... OF ........... .........................................................................
Trriifirtt#j� of (goutplitturr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by----------------------------------------------------------------------------------------- i--------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Worts Construction Permit No... ...... ----- ............ ......... dated- ....................... ....-.................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE yP TRUED AS A GUARANT HAT THE
SYSTEM WILL FU J�0'IOPI TISFACTORY.
DATE...... ... — -, c ............................. Inspect ... ...- --- -- . ................