HomeMy WebLinkAboutApp-Permit-ComplianceFss. S
PE0EUVE 01 THE COMMONWEALTH OF MASSACHUSETT,,S
oob_W BOARD OF " ALTH
........................................... OF.....�:-�.f`.............................-----...................
Appliration for Dispotial Works Tonstrurtion ramit
Application is hereby made for a Permit to Construct ()q) or Repair ( ) an Individual Sewage Disposal
System at:
..........._114ap
Location - Ad ress --- or Lot No.
.:�. _l�c.�_ t4 �S t:�t .. _P..R�..% ��.l.R►.x�►7� ...... ... fur`'-_.av!-!-- • e.., ...-
Owner Address
......---•••---------•
............................................. ..P. .A .. .?,�gxE/ ua l�.f►... �_�i�lr c�ar.f.g----------
Installer Address
Type of Building Size Lot.o21 5 Ca._..Sq. feet
aDwelling — No. of Bedrooms........3 ...............................Expansion Attic ( ) Garbage Grinder ( )
pi Other —Type of Building 492M ............ No. of persons ............................ Showers (t) — Cafeteria ( )
04 Other fixtures ........--•-•-------•---••-----•--••• .............. . ..... .
W Design Flow .... ...... &4 --------------- gallons per person per day. Total daily flow......... ��.V,6.............gallons.
WSeptic Tank — Liquid capacity.. gallons Length_... U _.. Width.-_ k o ,._ Diameter ................ Depth ... S-'-'! .....
x Disposal Trench — No . .................... Width .................... Total Length .................... Total leaching area -------------------- sq. ft.
3 Seepage Pit No ... l ............... Diameter ...... (P."' D-. Depth below inlet.... `' ----- Total leaching area ... ,5.3..._.sq. ft.
Z Other Distribution box ( X) Dosing tank ( )
Percolation Test Results Performed by .......................................................................... Date---------------------------- ...................
,aa Test Pit No. L." ---------- minutes per inch Depth of Test Pit..1Sk. A'----- Depth to ground water..---.�.1�4 .%?��a� �
Rt?"`
Test Pit No. 2.._.- .......... minutes per inch Depth of Test Pit__.�674.�...... Depthto ground water .=.._w�.lk...._
----------------•------------------- i -----------------------...... ........._.
Description of Soil __-!-'-AY��..TtP...5_t!�4i..S.!!t4.._._.^._4Q1.._�t
�.�......----•--------------------------•---------------------------------.....-•---•-----.....-----...•---------------•-------..........----------.......-------....--------
--------•--------------------------------------------------•-------....................----------------------------------------------------------------------------------
Nature of Repairs or Alterations - Answer when applicable.............................-----------------------------------
Agreement:
..................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITI.S 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation unt'1 a Certificate of Complia issued y the boar h h.
Application Approved By
Application Disapproved for the
Date
Permit Noi7-�R� .D--.-------- ------------------------------------- IssuedIL
--•-.....
ate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
—T _
o..w ........................ OF.Ylh4 !j OW .......................................................
Trrfifirtt#r of ' faontplittnrr
HIS IS&O CTIFY, That the Individual Sewage Disposal System constructed QK) or Repaired ( )
Installer
at_-�-� T.-`T_-34�_,t�lfl ,'f' L � cup, -Y� aur -.----------------------- -----
has been installed in accordance with the provisions of IT LEL, �` o he St to Sanitarl odea des -'be in the
application for Disposal Works Construction Permit N T %''?s7� ..c dated' L11�!� -1� J ........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE-CQNSTRUED ASA UARANTEF THAT THE
SYSTEMA WILL FUNCTION SATISFACTORY.
DATE ............. - -------- - ----- ......---• Inspec,? F�'.__. . _�_ �. .............
��