HomeMy WebLinkAboutApp-Permit-ComplianceNo. _aa...... Fmc.z.;.»..N..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O �HEALTH
OF.. ......................
...................
.-----------------
*..........
.....
Appliratton for Disposal Vurks Tonstrnr#ton jrrmlt
Application is hereby made for a Permit to Construct ( ) or Repair �an Individual Sewage Disposal
System at : �/�'j ems^ C�
f
Q (/-fZ— Co Owner
V_ ______ ___
Type of Building
Dwelling —No. of
Other —Type of l
Other fixe
Design Flow ...................
Septic Tank — Liquid <
Disposal Trench — No.
Seepage Pit No .............
Other Distribution box
Percolation Test Result
Test Pit No. 1......
Test Pit No. 2.......
Installer
.Id;/rl
ldin
jnutesmper
_......._ .Dosid by...
r inch
r inch
..........................
Description of Soil .....................................
........... ........ - - -....--------•--------------------- - --...--- --.....-------
-. or Lot No,
Address
J ^ � JC._._--
Address
Size Lot ............................ Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
No. of persons ............................ Showers ( ) — Cafeteria ( )
=........................................................................................................................
per person per day. Total daily flow............................................gallons.
Length ................ Width ................ Diameter ................ Depth----------......
.............. Total Length .................... Total leaching area .................... sq. ft.
...... Depth below inlet .................... Total leaching area .................. sq. ft.
tank ( )
---------------------------------------------------------- Date ........................................
Depth of Test Pit .................... Depth to ground water........................
Depth of Test Pit .................... Depth to ground water........................
-----.....•-------•------------------------------------------------•••--.....----------••-----•.---------------- --•-- ............_
Nature of Repairs or Alt e a 'qn�,'�-•wer wh lic,�ble_ ' ��
---------• .............•-•-...-•-•----- ......•-`.--......_ .._.:__... .`.�.---•-------------------'.......................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITUj 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance h s been issued bl�thhebo of health.
Si e �i !` _�
.................................... ---•-•-- .......... ...........
Date
ApplicationApproved By........ = --• ......................................................•------------•--•----.--•----�,=ZZ... .... -----
te
Application Disapproved for the f o wing reasons:---•----------------•-•-------•---------------•---•----•----------------------------•---••-•----•-•---••-.......
-•----•-----------------------•---------•-` -------••-------•-----•--•-----•-•------.....---•--•---•-----------•------------.......------.................-------•-•-----
Date
Permit No._ �? - ` .................................... Issu Date /l._U!?....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF ...............................................................................
Tntifiratr of Tompliam
THIS IS TO � IFYyy ;;That In Inti Sewage Disposal System constructed ( ) or Repaired
by..................... ...-----.....�.. = 5,1. L- .------ -----•--•-------•------•--------•-------•--•------•... ..:.......
y r +> Insta ler /� �.
at..__..-� .e%�' %1-�' •---•-.... �.......................- .........
has been installed in accordance with therovisions of T T f The State Sanitar C e d ib the
application for Disposal Works Construction Permit No ... !_____________________ dated __
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS "A TEE THAT THE
SYSTEMA W L _11 TION tySATISFACTORY.
DAT - _. i Y l . f 9 .. --- Inspect r.. ............. cG(-----...........................