HomeMy WebLinkAboutApp-Permit-ComplianceNOR -9-9a
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....... .C... ...........OF......... �'rLL1------------------------------------------
Appliration for Disposal Works Tons rur#ion Frrmit
Application is hereby made for a Permit to Construcl
System at:
l Location- Address
-- AV's �N_V--/
�ner
----- -�.. ...... ............................................. .....................•--------.............
Installer
) or Repair (--)--'an Individual Sewage Disposal
I `i
W - ......... or Lot No. rl i A P-_20
Address
Address
Type of Building Size Lot ............................ Sq. feet
Dwelling — No. of Bedrooms --------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures .-----•-•.........................................•---.....-------•---..............------.......-------•-------.........--•--------•------.....--•---
Design Flow .._..... x15 .....................gallons per person per day. Total daily flow....... � d .................. gallons.
Septic Tank - Liquid capacity ............ gallons Length ................ Width ................ Diameter ................ Depth ................
Disposal Trench — No- ------------_----- Width .................... Total Length.......--------..... Total leaching area ................... sq. ft.
Seepage Pit No ------- ............
Diameter ...... X::) ..1... Depth below inlet ---..:� �_...... Total leaching area .................sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-------------------•------- ..-- ---------
-------------•--.---------....... Date ........................................
Test Pit No. 1................minutes per inch Depth of Test Pit .................... Depth to ground water........................
Test Pit No. 2 ----------------minutes per inch Depth of Test Pit.................... Depth to ground water ........................
--------------------------------------------------------------------------------•----------------..........................................._....------•-----
Descriptionof Soil ........................................................................................................................................................................
..................................................... ------------...........---...............---•------------•----------------------- ---------------....._...----------..........._ ._._.........
Nature of Repairs or Alterations - Answer when applicable-----�. SZ �i .....: __..J• 6 ......... q.x.(Q..._ �`1.I..........
............ -ri -- ------ t _._ �`_...oticYs-rt N GS.Sii6eL •--
`�}...... .. - -
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance h�issued by the board of health,_74,
Application Approved
Application Disapproved for the
Permit No. Z::.91Q------------------------- __._.
AMit/e
..........
Date
Issu - -,D15 ......... -.......
---
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.. ` :'...w....N::.......OF........ .:... .�.<��..�, ........................
( ntifiratr of (anntplinurr
THIS I,_2Q CERT'TEr, T�at the Individual Sewage Disposal System constructed ( ) or Repaired
by-------- ................ ..... �------•-.
Installer
....
has been installed in accordance with the provisions of T TALE �. gf The State Sanitar Co. a as described in the
application for Disposal Works Construction Permit NoN r_: _ _ 3 .................. dated.........! 1./l K7.......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS G ANTEE THAT THE
TSYA STTTE .I WA�. L FUNCTION SATISFACTOR-Y.
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