HomeMy WebLinkAboutApp-Permit-ComplianceNo� ..z� Fn$.....�..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Towv�.............. OF .-...-`ra�!w.o J........
Applirattun for Di,ipuottl Works Tomitrurxiun lirrutit
Application is hereby made for a Permit to Construct ( Aor Repair ( ) an Individual Sewage Disposal
System at:
•---------------. c1e....Cl._......... .------------ `- Location _ Address or Lot No.1 --- .t''`om'=!n-,..........
----------------------- -- - WOo�s iD G l 2CLc..J.. .......
At?;!►nO....
W yy� Ill /+ n Address
Installer / Address
Type of Building Size Lot__`-E.�j.�`!S ......... Sq. feet
aDwelling —No. of Bedrooms ......_.._..?___________________________Expansion Attic ( ) Garbage Grinder ( )
Ga4 Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
d Other fixtures .............................................
----------------------------------------------------•----------------•••---------- ..__...
W Design Flow..............Ito -------------------
per person per day. Total daily flow ................ :3.3. .............gallons.
WSeptic Tank — Liquid' capacrty..td ..gallons Length. -O...!_.... Width;.41 ;_�...._ Diameter _____'—....... Depth.. � 1.___-7. ry C -t 6F?
x Disposal Trench — No ..................... Width .................... Total Length ............ ........ Total leaching area .................... sq. ft.
3 Seepage Pit No ......... I........... Diameter.._.__ AP ... Depth below inlet_______! ........ Total leaching area.. z6.7...sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by....................................••___________......_______..._.._.. Date___•________....____.__....________._- .
Test Pit No. 1_.<_Z....minutes per inch Depth of Test Pit ...... !3... ____ Depth to ground water...:_ .er
... JeusJ,
Lt.
Test Pit No. 2 ....... _-------- minutes per inch Depth of Test Pit ...... ► �.... ___. Depth to ground water ._»oL _�chcAAA1'f�
�i•-------••••-----------------------------••--•••--••---•----•....._...._.._-••--....._•-•----.....•• -•-•-----._......._.----••---•-
D Description of Soil -----0 �)-'ia
W -••m�f._,.�...- _._�&t—'VW 1 ._. .n........ tv.....
...
-------------••-•----...•-••--••-•-••-••------•----------••_..
----------------------•----•----.._....--•---•----•--------•---•-•------------------••••---------------•--•--------------•--=----------•--------...-------•---•-•-•------...-•---••.........-•-----_..U 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 TITL:, 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee ed by the bo ealth.
Signed . Ute' ... �...
• ._ at
Date .
Application Approved By -•----• -•-. I.c�. �.2..
Dat
Application Disapproved for the following reasons________________________________________________________________________________________________________________
...-------•-----•-•----••----•-••..................•-------------..................-----------.._.._......-----------•-------------......--•••--_------.-•........ .............................. .
Dau
-�----------------- Iued_.Permit No. ss - .Dlate
I
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THE COMMONWEALTH OF MASSACHUSETTS
/y BOARD OF HEALTH
............OF. .....................................
TrOftrate (auutplutnrr
THIS TO R IFY `Tha t e In vid Swage D,i� 7ste structed { ) or Repaired ( )
tal _.
at -- - �.
...
has been. installed in accordance with the provisions of TlZ 5 of The tate Sanitary Code s e r in the
application for Disposal Works Construction Permit No.___ _ll__ _ _ dated r_ ...
•
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE C NSTRUED AS A ANT E THAT THE ,
SYSTEM WILLI FURCTIONSATISFACTORY*
f �
DATE -•• ----•• _ .... �.2..L: Inspector ���”'.................
r