HomeMy WebLinkAboutApp-Permit-ComplianceNo.°..4.:.../.... �� Fas._1���.........._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...... ?n ............ OF.................G�....... _t l �............................
.app iration for Mopoottl Works Tonotrur#ion Flermi#
Application is hereby made for a Permit to Construct( or Repair ( ) an Individual Sewage Disposal
em at:
? / t 10 ( l 'an i dYY`l l 11)T�n t� ! rn o p _.>_e
Iu6t611eT AadiC96 ,r-�
Type of Building ✓Z Size Lot..-t8G.)
.........Sq. feet
Dwelling — No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder
Other — Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures ................... ___ ........ -rwvl...... ....................................................
- ----------------------------.........
Design Flow ........... ..... 1.112 .................. gallons per -per -son per day. Total daily flow .............. �:: ................gallons.
Septic Tank —Liquid capacity.... ..gallons Length..D..:6,R.. Width-tz:AQ... Diameter .... ..— �'✓�.. .+.
...... Depth..
ils osal Trench — No ..................... Width.................... Total Length.................... Total leaching area. .... ............... sq. ft.
4 e ale Pit No ........ I............ Diameter.,.?..!?...... Depth below inlet ... ._'1 ........ Total leaching area. %t - ..sq. ft.
Other Distribution box (✓r Dosing tank ( > `juru�� Conso 1 hen 1
Percolation Test Results Performed by.... �C:"...�J.......... Date. ......... 1'. `..�.. .......
Test Pit No. 1.......<.2..minutes per inch Depth of Test Pit ._.t2D........ Depth to ground water...... U _: i I.....
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
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 TITLB 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beftissued by the board health.`
Application Approved. -.--
Application Disapproved for the following reasons:
Permit No....d'&.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
11
......,.:G�. ..............OF......./.l. {/1/f/1'C::/'..........................................
farr#ifiratr of faompl ttnrle
THg IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
by......... ------------------------------------------------------------------------------------------------------------------
� Inst er f�-
has been installed in accordance with the provisions of TITIF 5 of The State Sanitary Code 2NTEE
cribed in the
application for Disposal Works Construction Permit No ..... �(.-.�7......... .. dated.... ......................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A G AR THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.........::....--...... :................................................. Inspector ............... ................................... ..................................
-21 Axl ............
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Date