HomeMy WebLinkAboutApp-Permit-ComplianceNoA
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
� ...
I..a..c,�,n�................ OF... %]JRM.bc..............----.------.--.---........-----.-----
Appliration for Dispaual 18orks Tonstrudiun 1hrmit
Application is hereby made for a Permit to Construct ( �orepair ( ) an Individual Sewage Disposal
System at:
.... S1: ... .... �lLocation ssY-Lot No.
M .? �j�M..............................._r [I .....�4 rt..:G!«..L.....
P...
Owner Address
..... ._ ,� 1,�.�il..�� %f'x G. ................................ i?. .,N..�
Installer Address +
Type of Building Size Lot ...2.3,4 6.. - Sq. feet
Dwelling — No. of Bedrooms----- ---------------------------------- Expansion Attic ( ) Garbage Grinder (
Other - Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures ----------•-•---------•-.......---•--------- ......
Design Flow ......... 5.�. —115 ......................... gallons per personr day. Total dail� flow........6.� .....................gallons.
Septic Tank — Liquid' capacity -155..8 -gallons Length ---fl, ......... Width;. -6 ........ Diameter ................ Depth ....� .
Disposal Trench — No- -------------------- Width _....1 �._..._. Total Length............ Total leaching area _.%.O ....... seft.6JV
Seepage Pit No ..................... Diameter.................... Depth below inlet.................... Total leaching area .................sq. ft.
Other Distribution box ( ) Dosing tank ) _ Q
Percolation Test Results
Z Performed by... S�... �.lt ?�?ry--......��� �►....-.-..- Date..Jf'!1V.. ��, .../.�.
Test Pit No. 1...............minutes per inch Depth of Test Pit ..... �.�>�o...:. Depth to ground water..i41.ON+O......
Test Pit No. 2.__ g Z....minutes per inch Depth of Test Pit ..... .--. �'1 . Depth to ground water.......dN.......,..
--------------------------------- ....................It ................................................................................_
Z 1' LIiAn'1 Z rig _M&�D KX) a.)L—r
Description of Soil ............ .•• ......----------
.54 '--
f (r �l..c !` ?�l..�fl�i?!5 .._..-ii......•.-...Z..... .L n -7,4" 1�A
Nature of Repairs or Alterations — Answer when applicable._..... ...............
r
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of :ITLI: 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the b rd of health.
Application Approved By.. -- z .............
Application Disapproved for the following reasons: ....................
Permit No .... g.........1%-•------•-- ........
------ ...... --
COMMONWEALTHC
BOARD,;, -01`F
LY�I'� lL LL Ci'i�
hat the. Ind vidual Sem
--------
r uc t
..
ructicin Permit No .. 1.x... , . d (p: _
RTIFICATE SHALL 'NOT BE ICONST
iFACTORY.
Inspect.