HomeMy WebLinkAboutApp-Permit-Compliancei
- kno124-' —1/4—cD le: ''' ' ,
NO.9 b. .... C.t5 k
— fe}(10..r2tAS' 11 44344
Fas..7
THE COMMONWEALTH OF MASSACH S
BOARD . F HEALTH
r ri°‘3
Appl ration for Disposal rr urku Ctunntrurtiun 4lerutit
Application is herebymade for a Permit to Construct .�/
PP� (�C) or Repair ( ) an Individual Sewage Disposal
iJ `{ ,// Location-Address or Lot No.
h
vei _ Owner Address
Installer Address
Type of Building Size Lot Sq. feet
1-3 Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
A4 Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
dOther fixtures
WW a Design Flow 5$ gallons per person per day. Total daily flow l 1 Q gallons.
W Septic Tank—Liquid capacity.coc, gallons Length..`(" Width 4`8" ° "
Diameter Depth o
MDisposal Trench No. Width Total Length Total leaching area sq. ft.
Seepage Pit No c Diameter I Ste` Depth below inlet Le` Total leaching area. ..`. ....sq-ft
z Other Distribution box ( ')O Dosing tank ( )
a Percolation Test Results Performed by law W
i et '2 �
Date G-1-2--Es-
Test'Pit No. 1 4- minutes per inch Depth of Test Pit.... .`1" Depth to ground water 11.pl-
fs,* Test Pit Vo. 2 minutes per inch Depth of Test Pit Depth to ground water
Ox j
Description of Soil . 'lam
W i s
o Nature of Repairs or Alterations—Answer when applicable
•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
4 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 been issue. by he bo d of he lth.
1 Signed. _.. r._41, _ ...t. .. ., /--n- ya.0/2Cr.
Application Approved By. . . .- � 7 go
Date
Application Disapproved for the following reasons:
Permit No 10- Issued 'S—2-GT— q
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
faertifirate of QIumpliunre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by
Installer
at.
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
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector
r