HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
t DVSt/. ............. OF ...... .1 �'k 1.4�u71/...............................................
Appliration for Dhipootti lRodw Towitrnrtion ramit
Application is hereby made for a Permit to Construct ()() or Repair ( ) an Individual Sewage Disposal
System at: 47
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li w ..1 . !L��i'E 1NC. ....................... 13 Q....R7 ' ��Nl.11ri...�l�<�?a6�lJ
Own r -Address
.............................�L��11 '-n-`�... /. Hi Wf..f....... •........ •----------------------
........
Installer Address
Type of Building Size Lot..'z011 .....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................... . ........ I... lions.
Septic Tank — Liquid ca acit li Qv.. allons Len th /..
P 9 P Yl g g. ��:.�`. Wldth.�.rr�Q'C Diameter....----..---- Depth.........
Disposal Trench — No ..................... Width.................... Total Length.................... Total leaching area............. sq. ft.
Seepage Pit No ... ..-1 .............. Diameter ... .. Depth below inlet..6 ......... Total leaching area..: �.!......sq. ft.
Other Distribution box ()( ) Dosing tank ( ) /2 / /�
Percolation Test Results Performed by..Z).W.E.I5:Z.&M................I......... ........... Date ...��.1.................................
Test Pit No. 141E ff :.minutes per inch Depth of Test Pit. (±......... Depth to ground water.. No. �
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
of
Nature of Repairs or Alterations — Answer when
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 t r signed further agrees not to place the system in
operation until a Certificate of Compliance has been i ed by�r oard of health.
Sined........ ... ... r2f(L ....................
Application Approved By...4-C ._c: �!� . y �.-�� �`
Date
Application Disapproved for the following reasons: ............ __ ...................................................................... ...................
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Date
Permit No........ ........................ Issued........... - ...................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................:.::.....:.......:.... OF.......::`:..:..::.....:.............................................................
(9rdifiratt of Tomptittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( )
Installer ;.
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......... dated ...............:.::..... s.. .......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE. i... A.1!2! .......................... _ ........... _ ........... Inspector ...... �....�✓Gv