HomeMy WebLinkAboutApp-Permit-Compliance............ .........
No ...... Fimis...J3. ......
THE' COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............. r _14W ......... 0F...y/?.RM0qXH ...... ..............................................
Appfiration for Disposal Works Tonstrurtion jkrmit
Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal
System at:
tr.2 , DpijklF
•............................... . ........
.......... P!�/IVSJMA ......... ......... !2�3_6 ..........................................
L2 L tion , Addressr Lot No.
................ — > 0 P" W.L.1 66� .................. up)LA
.. .......................................
Owner Address
... ............
................... ....... I.- Zell . .................................................... .... ...................
Installer Address
Type of Building Size Lot --- /S,,z.Q_7ZS --____Sq. feet
Dwelling —No. of Bedrooms .......... a ............................. Expansion Attic Garbage Grinder ( )
Other—Type of Building ............................ No. of persons_________._____________.____ Showers ( ) — Cafeteria ( )
Otherfixtures ......................................................................................................................................................
Design Flow______________________s .....______gallons per person per day. Total daily flow ............... XTIJ .................. Vlons.
Septic Tank— Liquid' capaci /.Oco ngth_J1a!:n(aY.. Width.l'– 'O.'v- Diameter________________ Depth.f.-nA."
ty� .. 0
Disposal Trench — No_ ................. ::: ---- gidt ............ .. ... Total Length____________._..____ Total leaching area ..................... sq. ft.
&--g I
Seepage Pit No.______!._._.______. Dia4er_&.(4.2,L , e,pth below inlet.fel ........... Total leaching area -2.0.1 ...... sq. ft.
1.1 0
�q .............
Other Distribution box (VQ Dosing to
Percolation Test Results Perf med by . ...... .......................................................... Date..
.81
.... .. ...........................
Test Pit No. I kkSX2.-minute er inch epth of Test Pit. -/3,91, .... Depth to ground water.Ah� ... W*r6w
Test Pit No. 2 ................ minutes per inch Depth of Test Pit__.___._..______.__. Depth to ground water...___.________.________
.......................................................................................... ...............
Description of Soil .... CL E–
.....................................
F
..J.qE.
........................................ . ....................................
...................................................................................................................................................
Nature of Repairs or Alterations — Answer when applicable__________________________________________
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Agreement: "?
The undersigned agrees to install the aforedescribed Individual Sewage Disposq., System in accordance with
the provisions of TIT iE 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 board of health.
Signed.
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/
Date
Application Approved By.............�r-- --------- ------------------------ ............
ate
Application Disapproved for the following reasons: ................................................................................................................
....................................... ..........................................................................................................................................................
Date
apPermit No --------- ------------------------ Issued ------------------ I _ ........................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......................... I ............. 0 R� .................................................................
fitwrti fir
%loof Toutpliattrit
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (
) or Repaired
by ------------------------------------------------------------ ................................................
.4 - - ----------------------------------------------------------------
% Installer
– -----------------------------------------------------------------------------
at ..................................................................... j
rc Com
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Cody as dpscribed in the
application for Disposal Works Construction Permit No.__ J�/_, ")
.................. dated __- L-1.0.1YI .....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE C NSTR:UEDAS A GUARANTEE THAT THE
SYSTEM WILL FUWCTIONAATISFACTORY.
. �Zc .............
DATE ......... 5/�2 .......................... Inspector _ .....-----------