HomeMy WebLinkAboutApp-Permit-ComplianceNo........ �.:r ��i FEs.... . �- �....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ,�-7OF HEALTH
........ OF .... y1.`!!.Rmao- --------------------------------------------•--
App iration for Dispoiia1 Works Tontrurtion rermit
Application is hereby made for a Permit to Construct (X or Repair ( ) an Individual Sewage Disposal
ystem at:
�.► ®T � 3 %il1cST (1 14JV Lr
.................•--...... ...----•----------- ..,.....� J�� ...................................................._...._..
o ation - Address
- ..... �3 t� - --1` A "ar � G ---- .._1. 73. 1 ,r -, !' t�'-- 4! :-------
Owner Address
Installer Address 1,e— 7
Type of Building Size Lot....................L-.-__.-Sq. feet
Dwelling — No. of Bedrooms ............................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures ... -----------•-------------------•--------••---......._.-----------------...------------...-•--
Design Flow -----_--_--.-_-------. ��----_gallons per person Ver day. Total daily flow ..................... 3.� Q -------- gallons.
Septic Tank — Liquid capacity .AO4..gallons Lengtht.'V�.. Width -V -1-O.".- Diameter ................ Depthf_° _ f..
Disposal Trench — No ..................... Width___... -------
_..._. Depth below inlet--_............. Total leaching area.-_ 0.1.......sq. ft.
Other Distribution box (b(,) Dosing tank (
Percolation Test Results Performed by a&_e .5'F...............rI._....._........._. Date... __ .............
Test Pit No. 1�-�et minutes per inch Depth of Test Pit.-�3.49...... Depth to ground water./b_.W�C
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water .........................
---•---------------------------------•--•-----•----------------•-•----.......-•-•--------------a-------•-------•----------•-----•--.....--•---•---•.-----
Description of Soil..... t%t / Lc .....)i d..-..0 &105 36� 0 '� ��� �}!U�! S!'uk38w z
...................•------.
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Nature of Repairs or Alterations — Answer when applicable_.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITI,a. 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed-------------------------------------------------------------------------------------- ----------------
e
Application Approved By ............. ---------- ---- ---- -------------------- -------------
4a-te ate 1'1
D
Application Disapproved for the following reasons: -------•----•-•---------------------------------------------•-•-----------•----••---•--------•-•-----------•----
-•---•---------------•-----•--•-------•.....-•--------J -
--------------•-----•----•-----•••-•------------•-•---------------------•--•--•---•-•--•--•-------•-•----•-•----------..........--••--.
Date
Permit No .............
------ Issued`1
ate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
�
rrtifiratr of Toutpliatta
THIS IS TO CERTIFY, That the Individual Sewage disposal System constructed (y) or Repaired ( )
by...........................................................................................................................................................................
_jstaller _.,
at........................................................................................ ¢ l-"t°�_,�:__L_.� .!
has been installed in accordance with the provisions of TITLE LE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit Na. (.1:_. :; .�..................... dated -------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE STRIIED AS A GANTEE TUAT THE
SYSTEMA WILL F CTION SATISFACTORY. �...
DA TE........�J�� .. Inspector