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HomeMy WebLinkAboutEngineered Plans - Rev. 1981Z 0 W U U N®..• FEz THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7 .. 04�./V ........ OF.... M--,,r112jVjV_T1X ----------------------------------- Appliration for Disposal Works Toustrurtion Prrmit Application is hereby made for a Permit to Construct ,§ystem at: Location - Address .... WAU ................................................. Owner .... �b_v ------------------------------------- Installer Type of Building Dwelling — No Other — Type ) or Repair ( ) an Individual Sewage Disposal ............... k!�� -42 .......... ---•---•---• -------------- ........... e� ..................................... V Address ....................... Ie Address (� ......................................... Size Lot --- ./ __o6l ..Sq. feet . of Bedrooms -------- �3 ...............................Expansion Attic ( ) Garbage Grinder Wz� of Building ............................ No. of persons.-.-_____-_.__-------__-__-- Showers ( ) — Cafeteria ( ) Otherfixtures ................................ ........................................................ ........ .............................................. Design Flow.. --...__S4 ......................... gallons per person per day. Total daily flow ----------------- 1_1-0 ............... gallons. Septic Tank—Liquid capacity/aOOgallons LengthY.`jL'.Width.VZ 'Diameter.-//'.�.--Depth.-S-.".-? Disposal Trench — No ..................... Width_....__,.........._. Total Length .................... Total leaching area .................... sq. ft. Seepage Pit No --------- / --------- Diameter ....... Z ......... Depth below inlet....-._._._._.. Total leaching area.,.;?P.Q ... sq. ft. Other Distribution box (Y,5.) Dosing tank Percolation Test Results Performed by._.... ...... SeIP& r ..................... Date...... Test Pit No. I ---____minutes per inch Depth of Test Pit ..... Zr----- Depth to ground water Test Pit No. _....minutes per inch Depth of Test Pit --_C ......... Depth to ground water.- ........... ......................... ��:r ................................... ................... Description of Soil ......... ,30.--- ------------_------------ 0. 71a /v ---- -------- --- ..................................... -P . ..... 42 ... .... ---------------------------------- --- ea_414ve ... 4 ......... 70 �:;Oj Nature of Re�*irs or Alterations — Answer when applicable ------------------------------ ................................................................. ................ i ......................................................................................................................................... .............................. Agreement: _, The undersigned 'agrees to install the aforedescribed Individual Sewage Disposal System in accordance with theprovisions of 'TTLE, 5 of the State Sanitary Code —The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha been issued b t rd of 1, Ith* S1 44 ............ ....... ................. ...... Sig e .......... ........ ............ .......... to ApplicationApproved By.. -'s ... ...... ........ . ............................................................... ------------- A D e Application Disapproved for the following reasons: ........................................................................ ---------------------------------•-•--- .---------------------- ...................................... I...................... .......... ............................ ............ Permit No ....... <-g) — ( I, . .......................................... ................................................... Date Issued- ........................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................... 0.41P./V .... OF ...... /.Z.7. ........ .......... .. at Qurrtif iratr of Toutpliatta THIS IS TO CERTIFY, That. the Individual Sewage Disposal System constructed N- or Repaired 1y\ by.. --------------- ............. ..... Installer ------------- .................. .. ------- ---------------- I -------------------•------- at..- ------_----------_ 77, , I iaIr has been installed in accordance with the provisions of TITLE 5 of The State nifary Code as described in the application for Disposal Works Construction Permit No..___ - _------------- dated___. __ .................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A THAT THE SYSTEM WILL FUNCTION SATISFACTORY. — 'a DATE & ................. �-�[02 ............................................. 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