HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MAS!$ACHUSETTS
BOARD OF HEALTH
....................... TOWN .......... OF.......... Y,,&E�loU_�............. .
Appliration for Maposal Yurko Tousuvrtion ramit
Application is hereby made for a Permit to Construct ()() or Repair ( ) an Individual Sewage Disposal
System at: MAP Dr
.......136 _ SU LLi vA til �o A D 1N:..X.AR1`f 0 VYW-- - 4 -�S_25 .---•- ---••-
ovation ddress .Lot..-o.-•-�
LS 66 t4,4
w....r..nc'
Intasler Address 11, 1J`- 5
Type of Building Size Lot .-------�-----------------Sq. feet
U
Dwelling —No. of Bedrooms............;; n........................... Expansion Attic ( ) Garbage Grinder ( )
Other —Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Other fixt res.... ..................• ._.. ....._......
----------------------------------•---------•-- .._.......-------•--
WW Design Flow ...... 4Z ..................gallons per person per day. Total daily flow ---------- 2 ----------- ............. gallons.
WSeptic Tank— Liquid ' ca.pacity_!QOD..gallons Length ................ Width ................ Diameter ................ Depth ................
x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area ................... sq. ft.
Seepage Pit No ....... i........... Diameter.---.....�....... Depth below inlet ........ 6......... Total leaching area .-.Z01 .... sq. ft.
z Other Distribution box (X) Dosing tank
Percolation Test Results Performed by--------------------------------- ----------------
-1----------------------- Date .................... _.
,aa Test Pit No. 1....<.Z .... minutes per inch Depth of Test Pit....-rJ_�Z_.. Depth to ground water .._.....
E� .....
Test Pit No. '2 ... <... Z -.. minutes per inch Depth of Test Pit.... 1 2:........ Depth to ground water................v �
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il
O Description of Soil---.--- ....... ................
.----•-.---------•-----------•----------------------------------------•------------------•-----------------------------------------------•------------ ---------------------•---•-----------
----------------•------•--•--------...------•--------•-------•--•---------------.------------------------------------------------•------------------------------------- -----------------
U 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 TITIE 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 d by the boaf2 o iealth.
._.
Signed ........ ...-- -----------•--.......
...... 7- .2.._1 ..-.8...9
Application Approved BY.. .�....:Datt —
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._
....
.... Date
Application Disapproved for the following reasons: ..........................................................................................................
..........................•-----------...-----------...........-•---•-----------.........--•--------•----.----•-..................---------.---.-.------- ...--•-•---
2 Date
Permit No.. - ..' _. r.z.-•----•--.....
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�IARMOVTN
...................... O1�1.�1.......... OF ..................................................................
Trriifirair of TompItaurr
THIS IS TO CERTIFY, (That the Individ Sewage Disposal stem construe or Repaired ( )
bv..........1�ra........... �.?L�:t�..1`r �......:--......--•..........
has been installed in accordance with the provisions of TITIE 5 of The State'Sanitary.Code as described in the
application for Disposal Works Construction Permit No` 5_.�,�_.:._ '' dated.--''..�f ...............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE N-S•TRUEDL AS _ UARANTEE THAT THE
SYSTEM WIL !UNCTION SAITSACTORY.
DAT . . 5_7-E63
..... Inspector.c---
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