HomeMy WebLinkAboutApp-Permit-Compliance (Cottage)i
i
No ......... Fus.....
- THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..1O............ OF ........ �,�./'t....�?.V ..! ----------------------
�R.
Appltration for Uispviial Workii Tonstrurtuan Frrmit
Application is hereby made for a Permit to Construct 0(� or Repair ( ) an Individual Sewage Disposal
System at:
L Address -7r Lot No.
Own Address
a------•------------------ 1�=--------------------------------------------------------...._..............----------...-----------------------------------
Installer Address
U Type of Building / 1 Size Lot_ AJ t--A-Q.9 ...... Sq. feet
Dwelling —No. of Bedrooms--. 2-.. ......... Expansion Attic ( ) Garbage Grinder ( )
Other — T e of Building
a
Other—Type g ............................ No. of persons ............................ Showers ( ) —Cafeteria ( )
Otherfixtures ---------------------------------------------•--------.----------••-------•-•------------
W Design Flow --_.._.___ 2 �Q--.--_-------------gallons per person per day. Total daily flow ---------------- --.______------gallons.
WSeptic Tank — Liquid'capacityaol-gallons Length_ ............. Width --- ?.0c..`...... Diameter-_______-___-- Depth ----i�.�._...
x Disposal Trench — No ..................... Width ...7 --------------- Total Length .................... Total leaching area -___-----•-_---..--sq. ft.
Seepage Pit No .................... Diameter..._..6........._. Depth below inlet ....... Total leaching area.. - ...sq. ft.
Z Other Distribution box ( ) Dosing tank ( W 9X / f 0 7&A1,6 ifs' 2f 10,
a Percolation Test Results Performed by ...... ............. .................
Test Pit No. 1._ �..Z._minutes per inch Depth of Test Pit ... //..._...._.. Depth to ground water ----- e ..Q._....____.
11 Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
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Description
------------ Description of Soil eC .....��� 1.. 1-.Q.;L 9''--------1 _/ ------:;—A . ..........................
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Nature of Repairs or Alterations — Answer when applicable..............................................................................
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Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T ITIS 5 of the State Sanitary Code — The under igned further agre s not to place the system in
operation until a Certificate of Compliance has been ' . ued by the, b =�h&//
/
i� Signed-• •-- -• ` fl % /4?
- • - -----------
Application
A lication A roved B �� � ate
PP PP Y -----•-•------- ---- •--------`Jl-
D e
Application Disapproved for the following reasons:----•--------------------------•------------------------------------------------------.. •--•-----...........
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Date
Permit No.---........ _all ....--------•------- Issued -----------------4 -- Z4 --
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THE
-- -
te
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................. Gert/.... O F... */:!;/ P�
Tntifirair of Toutpltana
THIS IS TO CERTIFY, That the Individual Sege } i1,4 al System constructed ( rr Repaired ( )
at.................. ------------•-------
has been installed in accordance with the provisions of TIT F 5 i e State Sanitary Co bed in the
i
application for Disposal Works Construction Permit No . `_____P _��.............. da.ted--.._-- ---
.............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE. - l�•----z S-•iP-------•--------- Inspector ------•-------------- `�