HomeMy WebLinkAboutApp-Permit-ComplianceNo. 83-95--..-.---- FunicQQ.........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
'I'OWL`1....................O F.................... YAI�IOUTH
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Appliratiun for llhip o al 19orks Tonstrnr#iun ami#
Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal
System at: Z- 07-- 2-,q /9 Inop-31
_ 39 G IMSON AVENUTE s _ W. Y - -----------------
Location - Address or Lot No.
AIB=I
K.B.H. , INC. Owner Address
.._.....
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling — No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building .......................... No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures --------------------------------------------------------------------------
Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid capacity ............ gallons Length ................ Width ................ Diameter ---------------- Depth ..... _..........
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No -_------------------ Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by..............................................................•--......... Date ........................................
Test Pit No. I................minutes per inch Depth of Test Pit.. .................. Depth to ground water .........................
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water.___.-.__._------_..____
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Descriptionof Soil ........................................................................................................................................................................
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Nature 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 bei} is
u�d by the boardhealthi,,
Application Approved By
Application Disapproved for the f ollowio§ reasons:...
a/14/aa . •---•----.--
Date
....................
Date
Date
Permit No....s3':.-,r $--------------------------------- Issued ----------- =C�-----.�...................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..............M................. OF ............... YA&Di 77 �3............................. ................
(9rdifiratr of T.omptianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (X )
by............ ....................................................... ---
Installer
at------------------------------------------ 39.. [ZAS_.......A i -WsYt.------------------------------•--------------•--•-•---------------•----------------•---------------
has been installed in accordance with the provisions of TITLW 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ...... .!!95 ....................... dated ----- 31108.3..........................
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT STRII@® GBJARANTEE AT THE
SYSTEM WILL FUNCTION SATISFACTORY. a.
DATE...... 3 ...... `S .................................... InsPec -