HomeMy WebLinkAboutApp-Permit-ComplianceNS'ouih ` a � , u''lt, ����� t1�::.�r4 � Flea...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH C
. ........................ ----........_.....O F......................................
,Z ppliratio t for Disposal Works ( onsirurturn throat
Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal
S stem at:
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LocationAddrorLot No.
e...- -• ------•---•............................. ............................... •••----• ...------......._..........................
OwnerAddress
,Wa = + C Con VVVS_I�n
-..................... ... - ........... - - ------......... ...... ................
Installer Address
Type of Building Size Lot _____.1:,.1.� .... Sq. feet
�. Dwelling —No. of Bedrooms --------------3 ------------------------------ Expansion Attic ( ) Garbage Grinder ( )
WOther — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures ---------•----- -------•----....-•--------...-•---•----------••...-•-•--....-•--•--------•...................•---....._............--........-•-•----
w Design Flow.................5 .................. gallons per person per day. Total daily flow .......a ........................ gallons.
a' Septic Tank — Liquid ' ca.pacity.L p o O.gallons Length... � 1----- Width .._..y..'.----- Diameter ................ Depth... .........
Disposal Trench — No. .........!......__.. Width ..... L 0.' ........ Total Length Z Total leaching area.3.23._�t__. t G • P. C
Seepage Pit No........_.f........ Diameter .._:10:.......... Depth below inlet .................... Total leaching area .................. sq. ft.
z Other Distribution box (X) Dosing tank ( )
a Percolation Test Results Performed by... L_ 4 W .._1.... W E_l---2-_-- t.!u G Date _-��/� a,3��.....
Test Pit No. 1.... c_ _minutes per inch Depth of Test Pit .....4 4__"_.... Depth to ground water ... ;?O......... _..
per., Nest Pit, No. 2 ----- _._minutes per inch Depth of Test Pit..... Z "... Depth to ground waterj., ...
P4-----......_�/1—+J---------------------•------...-••-••......-•••••-•-•---- .........................................................
ODescription of Soil ........... -- s Ems........ ............................................ ...............•----••-........----....---._.....................•-•---•
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UNature of Repairs or Alterations — Answer when applicable................................................................................................
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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 issued by the boardof ealth.
Signed .... YX 4- �. --- 4f -------
Application Approved By ...... U?11.1.�s J ..............
Date
Application Disapproved for the following reasons---------------------------------•-------------..........------•--•-•--•-------•-----------•---••--•---••--...._
Date
Permit No ..... $r�.`21 ............. --.... Issued .........117.11£35
Date
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Y�l
.................. T..................OF....../............................................................................
flrrxifirttte of Tomplianrr
TIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by .... ...�Pt....:........................•-•-------------•-•-----------------------------..---..-----------•--•--•--------------------------------
----------------
edInstaller
at----- LA... l`�__-�-.---C _::_ � k� . ..... ----------------------------------•-----------...------......--------•---.........--•---......--------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
�!_/_Zi--- ---$.S ...................
application for Disposal Works Construction Permit No .... _ _..__?1 dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.