HomeMy WebLinkAboutApp-Permit-ComplianceINSPECTION DATE/TIME:
M/P # � S 11
No. ._l..Z.•�� Fss...��
THE COMMONWEALTH OF MASSACHUSETTS Ig�r�
BOARD OF HEALTH
----..TOWN..................OF............. ../'-- .l.-`�-........--- c
`r
Appliration for Disposal Works Ton,strartiun Prruti# a
Application is hereby made for a Permit to Construct (`�or Repair ( ) an Individual Sewage Disposal
System t:
VU /y A�� -.?y L16,1�1
- ..
Location - Address or No.
kris_PV-l5--__---__�___________________________.......................
- - - ... U...... .....I..... --------._..............--
Owner 2 A No.
Installer Address 176 V
Type of Building �[ Size Lot .._._..._.._..................Sq. feet
U Dwelling —No. of Bedrooms___________-------------------------------- Expansion Attic ( ) Garbage Grinder (SCJ
Wd Other — TYPe of Building --------•------•------------ No. of persons ...........................- Showers
Cafeteria ( )
Other
fixtures...................................
x �*7iZctd'
w Design Flow ................ ------=------------gallodi.y. Total day f1QW ..........................
•--- .._O_}o�ns...
,/
—Liquid capacity._®WSeptic Tank ._.... /Diameter ................ Depthrl___
Disposal
Trench — No . .................... Width .................... Total Length ........ ._..._.._. Total leaching area .................... sq. ft.
� : Seepage Pit No .................... iameter......... Z -.. Depth below inlet ...... ....... Total leaching area___ ��.3.sq. ft.
Z Other Distribution box Dosing t ) �-
Percolation Test Results Performed by .... .............................................. ate_______ ..__.... _._.___._.... {
a .Z' L ................. �
b� Test Pit No. 1_..�.______.mtnutes per inch Depth of Test Pit ___..__.. Depth to ground water .... �7 .�
__.___..�
44 Test Pit No. 2 .... �_.Z- __
minutes per inch Depth of Test Pit._/.5L___..... Depth to ground water... --Z. -----------
P4.............................. .. _.____Y.._.....________...------
-751-
0
_
O Descri tion of Soil__ G . -- 2 .... -_ G, fes, rL '� �` �?? IA
P !�
w
UNature 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 TITLE'5 of the State Environmental Code — The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by th board of health.
Si ed -C ........../ Zo� `�►
`Q�/�� . ........ .......................... .......re . _..._ -...
�,�c
Application Approved BY ---------------------------
re
Application Disapprovedor the following reasons- ----------------- --------•--------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------- --------------------------------------------------•-•-----.............--
- ------ -------
Da
777
Permit No. ------- --,2-,2�f..................... --------- Issued................-I�
Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH ,(
TOWNOF ------------- �---•.................................................
�er#t#tra a of (gomp.Cintre
THIS IS TO CERTIFY, That the Indivridual Sewage Disposal System constructed or Repaired ( )
by----------------------------••------------------------- -. 1. /1t..........:...... i /G..---------------------------------------------------------------............................................
at ...-J(/GG/.(.0 !V....------ vii '-----------------------------------•---- .............. ................................................
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code Vec •b d in
the application for Disposal Works Construction Permit No. .... 2J��................ dated .........�..- 6� ............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUEDAS GUARA TEEAT TTHE
SYSTEM WILL FUNCTION SATISFACTORY. i'J
DATE------ .. =..7- ---- ....--------------- Inspector . ---- --- -------------- ---- --- ----- ------------ --------------