HomeMy WebLinkAboutApp-Permit-Compliance` No ..............FEs.........�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
To ", �c YZ Nr`� -?-mac ...
.................................---.....O F...........
Appliration for 11hip sal Works Toustrurtion rrrutit
Application is hereby made for a Permit to Construct (k) or Repair ( ) an Individual Sewage Disposal
System at :...._......... N y o)T K5 C 1 �kc L ..............
Location - Addressor Lot No.
...._� .... `. .. _......................................................... ....------•--.......--•---.............................
►.a `` Owner Address
�.(.._..... Q ...................................................... ....------ ------ ---•-------
Installer Address
Type of Building Size Lot.....!9. 3`? 5 -Sq. feet
aDwelling —No. of Bedrooms._..._Y _`-' ........Expansion Attic ( ) Garbage Grinder ( )
p, Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Lt, Other fixtures .......................... ._.........................................................................................................................
W Design Flow______________ i5_13 capac.__..___._.__.....gallons per person per day. Total daily flow_..-.......��?..�_✓........:__......_ lons.
WSeptic Tank — Liquid ity./�� jRgallons Length-__- Width:r�'_'.5 . Diameter ................ Depth.- CFF' •
x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No..... Diameter... z 4�—`77�7 Depth below inlet._' !— : Total leaching area _443.` -t -sq. ft.
Z Other Distribution box ('c) Dosing tank ( ) �-�*� I Glj
'-' Percolation Test Results Performed b ..............1� ..C-_ .. �....:-.--..---......-. .. Date.... __. ?-.................8//))
Y .
,aa Test Pit No. 1.... .Z ---minutes per inch Depth of Test Pit..... �.z- �;__ Depth to ground water...0 1st ....
ri, Test Pit No. 2................minutes per inch Depth of Test Pit ....... ...... Depth to ground water... ZE.?4L......
................
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O Description of Soil ......... '-z•- ot�-- sc� h ,� Z--�b s� !`+,r'o j Go -14-`........ j
"rti lean M Sar-► � •off-Z�.-••t-1�"►-• vim._._.... -•----S..... i ._ �?-----•--
V}�... c l�
------------------- �� ' Z a S' . ` a�.....� 40- - t '�..'F!-t ...... ........
U Nature of Repairs or Alterations — Answer when applicable...............................................................................:i -10' A....
a
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Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ys d b/ytt e bo- of health.
�-l7Signe......
-�•�=� ............................... .......... y
Application Approved By.. -- •--•- t l!�---•--•---------------------------------------- .......
Date
Application Disapproved for the following reasons: .............................................................................................................
Dau
PermitNo... i .��....... �---------------------------------- Issued ...... -•-----� I � 5 ............................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF ........f.......................................................................
(Irrfifirate ,af (Fnutplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (k -`'j- or Repaired ( )
by..... t..........l4Q AS: -j ........: ---------------------------------•---••-•.--• ......... _..._.... .............................................
�} Installer
at_..' (_? ±_ �i k3f.< ..------------------------------•---------------------------------
...-•--•. ........................................ ----- --
has been installed in accordance with the provisions of TTL_E 5 of The State Sanitary Code s described in the
application for Disposal Works Construction Permit No..6_`........ `................... dated_.'�P i 1-7--- .....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WI&L FUNCTION SATISFACTORY.
�jf Inspector 'f._s:_ Q
DATE..............•-�---......................................................-�3 -----•-----.-._.............................