HomeMy WebLinkAboutApp-Permit-Compliancel;
No...lJ....��.�(Z� Fxs../.....- ..
THE COMMONWEALTH OF MASSACHUSETTS
_ BOAR® �OF HEALTH
®er3sl..............OF...................................................
Appliration for Dispaiial Works Tomitrur#ian 1krutit
Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal
System at:
..r..°sq4
........................................................... ......._---�--....-----..c�1
.La�j:7zG64%471r�= nx�7--------------
Address
W............ ........LIZ,. ---..4-1..4---..............................
Installer Address
Type of Building
Size Lot__�M A?3$._._Sq. feet
Dwelling — No. of Bedrooms .............. . ...........................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Pa Other fixtures --------------- --------------- -
W Design Flow ............................................ gallons per person per day. Total daily flow ........... ------ _---------- gallons.
WSeptic Tank —Liquid capacity/ P.gallons Length ................ Width ................ Diameter ---------- ..... Depth .... _...........
x Disposal Trench — No_ ____________________ Width .................... Total Length .......... _......... Total leaching area .................... sq. ft.
Seepage Pit No--------------------- Diameter.... . ... Depth below inlet ...... .......... Total leaching area_ FIFKI__sq. ft.
Z Other Distribution box (yd) Dosing tank ( f )
'-' Percolation Test Results Performed _..----�-�••......... Date_.._.��-•.............._--.
Test Pit No. i _:!59Z___minutes per inch Depth of Test Pit ..... !� ....... Depth to ground water_._ .��____.
GT., Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
Pd-•--•------•--------------•-- ------......-;----•-••••--•-••------•-••-----•-••-----.....--------------------•-----.......-----•--•----•---------•---------
D Description of Soil----- C?7
-- ar `-�-4" = C.cavi. i✓_••Su�6sc�ir------------------------------•-------•--------- ----------------....._......----------
Vz4-/44_' = `�'%gv� o�eay --sc�, sc ---••----------------------------•-----.......------•-------------------
W--------------------------------------------------------------------- -----•------•-•-•--•----•----•----------------------••-------------•--•----•------------•-------•---•-•---------•-•-•----•....----
VNature of Repairs or Alterations — 'Answer when applicable...............................................................................................
-•--------------------------•------•-----------------------•---------------•--------------......-•-------------------------------------------------------•---•-•-----•-•--•-•-------•-•--------•--------
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
therovisions of TITi..:.
p 5 of the State Sanitary Code —The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss the board of health.
Signed g ----------------
Date
ApplicationApproved By... ............................................................................................... ........................................
Date
Application Disapproved for the following reasons---------------------------------------------•------------------•--------------------. ..........................
............................................. ---•-•-------------•--••----•---•-----••---•-••••---••••--•--••--•--------•----•--••-•------------••-•-------------•---•----------•-------------•••---•---
Date
PermitNo --------------------------------------------------------- Issued .......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......... .......... I..................... OF .....................................................................................
Tntifirair of Toutplianrr
THIS IST- That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
b.... ........j..r_�E ��-----------------•------------•---•-----------------------------------------------------------•--------------...-.-------•-----•----------•-•-------------
y
--, '—T / �--• —' Installer
at.. i
...�-
has
been installed in accordance with the provisions of TITIN, j of The State Sanitary Code//as described in the
application for Disposal Works Construction Permit No ....... _ ............. dated.__.77t . Cr:___.• -_-_-_--------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO RITE® AS A G4 ANTE HAT THE
SYSTEM WILL F CTION ATISFACTORY.
.� DATE. --•--------------------------- Inspecto