HomeMy WebLinkAboutApp-Permit-Compliance,rNo. I J FRs ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD
�O�F�HEALTH
�Q4tl.�!--------
......... OF -----..:L " .................................
Appliration for Disposal Warks Tonstrnr#ion jJamit
( Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at:
T.---- • - - .YYl ia{� ►�
------ -
Location - Addre or Lo N�
Gj'
Owner CN dress
29,
Installer Address` 17� q
Type of Building Size Lot ......... ..................S feet
U Dwelling —No. of Bedrooms .......... _________________________•••_... Expansion Attic ( ) Garbage Grinder
a Other —Type of Building ............................ No. of persons_.-._.._...._......._....._. Showers Cafeteria
( )
P4 Other fixtures --•--------------------------•---- .
Design Flow___-_-__P!______--_-gallons per-ger-ean per _day. Total daily flow flow__-_••_3�®.--_•_--___•_•_•____--gallons.
W WSeptic Tank— Liquid caacit .lX�_ allons Len b`fc-_- Width4-Diameter______________• Depth-:V-A"...
x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area -__••_--.___________sq. ft.
Seepage Pit No-____._ I.._..._..__.. Diameter ..... .......... Depth below inlet ..... b............. Total leaching area -_-Z&7 ------ sq. ft.
Z Other Distribution box ()<) Dosing tank ( )
'4 Percolation Test Results Performed by ....................... '....
is . L® Date-----°a-��..:.................
aTest Pit No. 1... `�_.._minutes per inch Depth of Test Pit --- ikW......... Depth to ground water ........................
(:4 Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
----------•- --...............................................
Description of Soil ................. :3..............
___._... TSP_.. .. _!3_•_...._._.__..__
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 TITIL 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certifi
Application Approved
Application Disapprove
.---------••------------------------•-••-•-----••-•----------•------........
Permit No. -V—•15187 ----------------------------------
------------ --------------a-t-e-
------------------------
......._._
_______
p9.
THE
COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....... Wil Y.' �qq....................................
(In#ifirair of Tompliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed �!,) or Repaired ( )
by-------•--------------------••-•------------------•------------------------------------------------------------------•-----------------------------------------------------_----•-•-•----------•--
Installer
at... 7".._ G Z.._.. � :Sfh--/D� •• =s` ......----.L! .................. -Pq sir------------__- -----------____._.__._---------_-_____-----___
has been installed in accordance with the provisions of TSI,, 5 4f The State Sanita j1.. ode agile m the
application for Disposal Works Construction Permit No..................'..:.................... dated :.. _v._.___' �------...___.__..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS,4"� "4NTEE THAT THE
SYSTE WILL NCTION SATISFACTORY. �
DAT--•---- .................................. Inspect