HomeMy WebLinkAboutApp-Permit-ComplianceNo..A_ :.. 7.
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
------OF ............. o c� rho ................._...._........
Appliratiou for Disposal Works Toustrur#iou Fautit
Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal
System at:
�i.� C�.......?:!� 5...-r --' •fir f� J�.- s.�..�. - ' `
Address � .�----------------
�ssytion - /_ - or Lot No.
Qwner
-- � , nr? --------------- dx �f ......
Address
e 1 !av=---------Q? �?.,.......----
nstaller
Type of Building
Address
Size Lot -1% ,,j S:Z_._Sq. feet
Dwelling —No. of Bedrooms ............. ....................... Expansion Attic
(--) Garbage Grinder (— )
Other — Type of Building ............................ No. of persons ............................
Showers ( ) — Cafeteria ( )
Oter fixtures------------------------------------------------------------------- --------------------------------------------------------------------------------•-
Design Flow -------1 (2) ---------------------_-gallons per personper day. Total daily flow ----- ..................gallons.
Septic Tank —Liquid capacity_ llons Length .(:�=_' Width -.V
`O.' Diameter._I.`2r:_..._. Depth ..........
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area -.__----------------sq. ft.
Seepage Pit No ..................... Diameter .................... Depth below inlet ....................
Total leaching area .................. sq. ft.
Other Distribution box -`(w) Dosing tank ( )
Percolation Test Results Performed by--••--------•-----------•...............•----------•-------•------------ Date--- --- ------------
_
Test Pit No. L.1, �..r minutes per inch Depth of Test Pit .... 14�::-__-- Depth to ground water......
_
� ___. minutes per inch Depth of Test
Test Pit No. 2.___.._
Depth to ground water.,.'t.........
•---•--•--•------..] ............ j -------•-----• ........................ ...... ..........
Description of .:- _`
'z:'
lfcxf -------------------------•----------•--•------------------------.----------
-•-------------------------------------•--•------•----••-------•--•-•---••-•--•--•-----.---...---..------------------•----------•---------•------------------• ......................
Nature of Repairs or Alterations — Answer when applicable ................................ ..............................................
Agreement:
The undersigned agrees to install the aforedescri
the provisions of TITIE 5 of the State Sanitary Cod
operation until a Certificate of Compliance has heer}�'y gc
Application Approved By.
Application Disapproved for the following reasons: ...............................
Disposal System in accordance with
:er agrees not jo place the system in
1�10/_
'-Ile
ate
b'--- z........
Date
.......................................
............................................................................................................................................ ............................................................
Date
f � q
Permit No.---- ------------•--•---- Issued... `�-----------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
................ OF....
..SCh 1111e �%!'. l.............................................
Trrfilira tr of ( ompliattrr
THIS IS TO, CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired
by-----•-�--I-�.4A--------4J��....----_5;.X�_l ------------•---------•-•-------•-----------------------------------------------------------------
��r+ nsta ler
has been installed ih accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ..... t _.'............. dated ---- wl_'.'.��� ....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......... ------ZI-1------------------------•----------- Inspector.-- / -- •- ia'? ----------- -------•-----_-----