HomeMy WebLinkAboutApp-Permit-Compliance103
N 0 Y
FEB CT -01
Fps..../ .0 ............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF ......... X4.R.,M0..Q.7# ..........................................
. ................. as
for Diapaiial Works Tonstrurtion Famit
Application is hereby made for a Permit to Construct ( or Repair
an Individual Sewage Disposal
System at:
...............
.. 42r
_.Location -Address
.. ....... �/
...........S.
ell< ............................... ..... ....... 40
I No*
or
49
.4
fl
Address
Owner
------------------------------------- ................ . ................................................................................
76 Installer
Type of Building
Address
Size Lot.._ 16 2.0. Q .... Sq. feet
Dwelling — No. of Bedrooms ............ :�`.............................Expansion Attic kv6) Garbage Grinder (too
Other — Type of Building ............................ No. of persons-_---_-._.._._._--.__---.-
Showers ( ) — Cafeteria ( )
Other fixtures ------------------------------------ .......................................................
A6, A ------------ * ----------------------- -
Design Flow .......... //!..........................gallons per per day. Total daily flow .............. 7.3.0 .............. gallons.
Septic Tank — Liquid'capacity/40.0jP.gallons LengthH...4.r.". Width.17.�v';'_
Diameter ......... ...... Depth__5�..-,,
Disposal Trench — No ..................... Width.................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No...../ ........... Diameter_ A.4r.? .... ..... Depth below inlet...Total leaching area._,/<%<5 ... sq. ft.
Other Distribution box Dosing tank
Percolation Test Results Performed by.Rd/,1AS-Zk ----- 4. - -� e?5 _; E � e Pe, /Z`5, Date_..... 3
Test Pit No. 1,4L3� ---- minutesperinch Depth of Test Pit .... e.02 _- ------
Depth to ground water.Z_4!.t.s.!r ......
Test Pit No. 2 ----------------minutes per inch Depth of Test Pit ....................
Depth to ground water ........................
---- ---------------------------------------------------------------------------------------- -
'Description of Soil--------- -------- --------------------------------------------------------------------
............... Ze .. ........ W1. ...................................................................
.......................... 9;9, -'re ...... ZVAe4g!�IVW. .........
........................................................................................... .............................. ....................... .....................................................
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 TIT : E 5 of the State Sanita Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has �e`n issued by the boar-dof heal%
.1 1
Application Approved By ----- A&
Application Disapproved for the following reasons:...
ate
1.7 - ------------
........................................................................................................................................................ ................................................
Date
PermitNo --------------------------------------------------------- Issued --------------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
THIS
BOARD OF HEALTH
.............. ' 1. ...........OF......... V.. /� ...................................
Tntifirati of T-Onutpliana
JTII�Y, That the Individual Sewage Disposal System constructed<
) or Repaired ( )
--------------;# --------------7-7 ----- _--I--- Installer
x , ,
..............
..............
at-•-------- .......... ... ------------- 4 ---------_----
Code as described in the
has been installed in accordance with the provisions of TITLE.,. F 5 of ._6t
The S/te Sanitari/(
application for Disposal Works Construction Permit No ---------- I--- dated_ ------ ::! .................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT I CONSTRUED AS A 41UARANTEE T/HAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-------------------------------------------------------------------------------- Inspector