HomeMy WebLinkAboutApp-Permit-ComplianceNo .... Fiz&
THE COMMONWEALTH OF MASSACHUSETTS
--7-- BOARD OF HEALTH
cLerM.�
........................................... .
, ppliraffou for 11hipmal Works Toustrnrtiun ramit
Application is hereby made for a Permit to Construct (yj or Repair ( ) an Individual Sewage Disposal
-System at:
Le:&W �AA
..............._.... - ......................•.... r-••-----...............................•..............................
—
Location - Addres or Lot No.
.................... �0 y /_4-----------------�j .fZ_4� sJ1........ r��...... - j'•} _fie `�C✓� ,
..... .... -
Owner Address
-'4-- �'�'�rlsl "-----------------•. ` `'l._T "1 '------------------.........-----------...
Installer Address
VType of Building Size Lot....feet
,-, Dwelling —No. of Bedrooms .............. . ............... ........... Expansion Attic ( ) Garbage Grinder ( )
Other — TyPe of Building ----•----------------------- No. of persons ............................ Showers
( ) —Cafeteria ( )
Q' Other fixtures ................................. .
W Design Flow ............ ...............gallons per person per day. Total daily flow ........... --.* Ac> ................ gallons.
WSeptic Tank — Liquid capacity.IPP gallons Length ................ Width ................ Diameter................ Depth_....__...•.....
x Disposal Trench — No . .................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ...... J------------ Diameter ..... 19`_...._. Depth below inlet ....... &**------- Total leaching area.Z��A_7.sq. ft.
z Other Distribution box ( ) Dosing tank ( )
'-' Percolation Test Results Performed by._._f'�_YYI .._.d�G..�_ a-. P_ ............... Date ...�?,l 7.
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Test Pit No. l.. :<:?=..minutes per inch Depth of Test Pit ...... Vii...... Depth to ground water ...
44 Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
9•-----------------------------•--------------------------........--•-------........--------•---•---- --•-----------•----------------••---•-•-----------•-•----
D Description of Soil... ' � ,o Loam_ S ipso ----------------------------•------------------------------------•-----------.....-•---------
W•�4i mYsQ.. d
-----•------------------------•••Cuo--:i--- .... .-•-:-------------------••-----•---•-- ............................................
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 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 is d by the board of health.
Signe•-• .. -•-- -• --•-----------------------------------••...---
Da e
Application Approved By_ . ... 7`� -- - - --------
;4
------Z--Ivo_-a'-•Z----
..----•--------------------------------- Date
Application Disapproved for the following reasons-------------------------------------------------•------------------------------•-------------------------------
---------------------------------------------•-----------------------.......------------. -------------------------•-----------------------•------•••--•----•-•--•-•--••-•-•-----•---•---
Hate
Permit No.-- - 3 S? -----------•-•--------------- Issued _...... 12. _ / =...................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................................................................
Trrtifiratr of flaunt r�i�tnr�e
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
by....... 2/,�d----.-1 ... ................................................. .
_. Installer
at
Lvf _
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.__!?' 2------ ............. dated ------ ' :: --
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
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....................................... Inspector ... � x-6-9.............................DATE...: