HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........ OF...... ----------------------------------------
Alip iratiou for Disposat Works Tonstrur#ion ramit
Application is hereby made for a Permit to Construct ( 1,Y"o"r Repair ( ) an Individual Sewage Disposal
System at • r �O
Location -Address
...... JC.X",V)
....
----------------
Installer
d
Type of Building
Dwelling — No
Other — Type
U .......... rr�
T
Address
Address
Size Lot ...2— q. feet
. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( )
of Building ............:.............. No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures-------------------------------------------•----------.------------•-----------•-------.............................................................
Design Flow ............ `d------------------- gallons per person peri day. Total daily ?w ........ 3 �--------------•----•--•-gallons
Septic Tank — Liquid' capacity/ Ions Length..�v._....._-. Width... ...... Diameter ................ Depth___ ._....—
Disposal Trench — No . .................... Width.... ............. Total Length ............. r.---- Total leaching area .................... sq. ft. z•
__--• Diameter../...._..._. Depth below inlet•-•-�.2.........._. Total leaching area.:• q. ft� 66ft
Seepage Pit No..._,l.____ •-----.s
Other Distribution box (C�� Dosing )
Percolation Test Results Performed by..... Date.•.../--�i-_�A
Test Pit No. 1..... G ninutes per inch ep i of Test Pit.__/_. rte.. Depth to ground water .... 1,&f ......
Test Pit No. 2 ................ minutes per inch Depth of Test Pit .................... Depth to ground water ........................
........... ----------------------------------------------------------------------------------------------••--•--.........__.....-----------•---•--.---
Description of Soil %.-'.. ........ a v f_.. cJ ------------------------------- �i.�..�.....------.
G. V -------- &e ... =... ........ ,?c... -------------------------------------------------
Nature of Repairs or Alterations — Answer when applicable .............................................................................
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Agreement:
The undersigned agrees to install the aforedescribed
the provisions of TILTLE 5 of the.State Sanitary—
operation until a Certificate of Compliance ksteV issueO
Application Approved By --------------------------------
Application Disapproved for the following reasons:-
Individual Sewage Disposal System in accordance with
The undersigned further agrees not to place the system in
y the b health.
�----------------------- --- -- ---�-. �-
to y+
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.......... ...............
Dat
.-----------------•--------•---------------------......••-•---------------------------------•------------•---•---------------••--•--•-••-----••--------------•-------------------.
- Date
Permit No ---------- OP2, -_0 .............................. Issued.---------- -------
at ------
D
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�..vGf%i.1............... O F... r f.'JO Ci 1 ........------............
Trrtifirtttr of Tontpliattrr
THIS IS TO CERT FY, T!4t e Individual Sewage Disposal System constructed ( or Repaired ( )
at �- -1 -•--- t��171�rn��? � -= �ta� � --•--- � � = ���-� =------��������---`-=�/';
has been installed in accordance with the provisions of TIT r of The State Sanitary Cod as des `ribed in the
application for Disposal Works Construction Permit No... .................... .......... dated.._._._._����1_-�---------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE C TRITE® AS A GUARANTEE THAT.,THE
SYSTEM WILL FU TION SA ISFACTORY. //'
DATE....... ..... ........ ---------------- Inspector -