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Home My WebLink AboutApp-Permit-Compliance�i�3.:c.... - - •--- Fmc... 15.00........... THE COMMONWEALTH OF MASSACHUSETTS r BOARD Off' HEAL oF..........��1�/yicu.rid---------------------------------- Appliratiou for Disposal Works Cna nstrurtion ramit Application is hereby made for a Permit to Construct (,k) or Repair ( ) an Individual Sewage Disposal ....stem at • / CerCW 5 r nBS ....... L lz: Z Mi ocaf�`°� Address or Lot No. .....�i._Y..�7. f ..............................•...... ..................... ............................................................................ •----•...-----.... 1 .. ..... °��-'.� . 5 --•-----...---•--.........- Installer Address d Type of Building Size Lot__�9__.L ----- feet Dwelling —No. of Bedrooms............ Z...........................Expansion Attic ( ) Garbage Grinder04 ( ) '4 Other — T e of Building No. of persons ............................ Showers — Cafeteria Q, Other fixtures -----------_----------- d .................... �do -••- --- --- --------------- ZZ�Design Flow .......... /l_0.......................gallons per perk peday. Total daily flow -------------------------------------------- - -- --------------gallons. WSeptic Tank —Liquid* capacity./000gallons Length5!V= 6..... Width.4.:/0_ Diameter ................ Depth --- ;:�_-�- - x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft. Seepage Pit No ....... /-_____-_- Diameter._/lJ__ 5� Depth below inlet.__.EZ:-... Total leaching area ... Z�2..sq. ft. Z Other Distribution box ( ) Dosing tank ) / '~ Percolation Test Results Performed bY____ __ __1'!9 ................................................ Date ... Z ... ,1 _�_........ Test Pit No. 1... L._:?�._minutes per inch Depth of Test Pit .... 14_4... Depth to ground water ------ . ............. Test Pit No. 2................minutes per inch Depth of Test Pit. ................... Depth to ground water ........................ - S0 ! ----- -------------------------- Description of Soil_._8...-di..... ••-----•-•••---•--••-•-------- ....•... ..... �M_E•�..... ........................... ------------------------------------- •----•---•--•---.----- 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 TIT1E 5 of the State Sanitary Code — The undersigned further a rees not to place the system in operation until a Certificate of Compliance has been issued by the board of beakh. Signed_....•...... --- ••-----•-•...-•-•---•------------------------ ----- -..... .... D Application Approved BY-�+ -----•--------•-•----------------------------------------... ate Application Disapproved for the following reasons:----•-•----------------------------------------•---------------- ---------------------------------------------------•-----------------------. Permit No ....... 4P -L-13 ------------------------------ ........................................................................... Date P-L13------------------------------ .------------------------------------------------•-•----•------....-----•-- Date Issued- --•--....��1 ,1. ........................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................�7Gt1N .............. O F...... YA17C I7Tf I......................................................... �ira~tifirtt#r of f�u�a�li�tnrr ffEfSI$.,TO3 CERTIFY, That the Individual Sewage Disposal System constructed ) or Repaired ( ) Installer at . TAT � _ ET[,E t ST-_�F,�r J)_'; t� ?CE� --`�--------------------------------------------------------------- -------------------- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit Noal-1.8.3 ----------------------------- dated ___.__1{�$/'81........................... THE IS OF THIS CERTIFICATE SHALL NOT BE CONS UE® AS A GUARANTEE THA THE SYSTEM VILL.F.j�lInspector...._DATE.........•...... ..--•-TY X14)