HomeMy WebLinkAboutApp-Permit-ComplianceNa�...... F�$�...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD �fOF HEALTH
40 LA/A/...OF........ X/91Z�`7 vT°t .................................•-------
Appliration for Disposal Morks Tonotrnrtinn Vernfit
Application is hereby made for a Permit to Construct (r/) or Repair ( ) an Individual Sewage Disposal
tem at:
SyS�Va/z l.._.. / 7/07 ^-/ -•S7 s��114 /37ZO70 vim-/ .------ ...... ? f'-
Co �- _i3 70
Locatio - Address or Lott Np.
-- `�U /3��_a .. - =• �~/ .. - S� -. /liG -.
.........................................
Owner pp Address
W J
Z)4"40 ...........................................
Q•--.....-----•-••-......---
Installer Address
Type of BuildingSize Lot .... �?..a`�..... Sq. feet
Dwelling —No. of Bedrooms.............3 .............................. Expansion Attic ( ) Garbage Grinder ( )
Other —Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
aOther fixtures -----------------------------------------------------------------------------------------------------------------------------•-.--•-----•-------------
W Design Flow ............... _-----.--•----.---.------•gallons per person per day. Total daily ...................... gallons.
Septic Tank —Liquid* capacity-1odo.gallons Length..8 6....... Width..:I�'6...... Diameter ................ Depth. _-6=.8 ..-.
Disposal Trench — No...-.._--_----.---. Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No........�.--....... Diameter....... Depth below inlet....... G_ ... ...... Total leaching area_.Z3;�:�Lsq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'-' Percolation Test Results Performed by... L D! s9/2� : �E-Z.� OV --.....--. Date..`T�°'. ......Z�j /...86
aTest Pit No. 1_L. L: ..... minutes per inch Depth of Test Pit.... -/'Depth to ground water........-'.------.--.
Test Pit No. 2__.� . z___.minutes per inch Depth of Test Pit.....J ----- Depth to ground water.......- .............
t�•-••------•-•----•••--••••----•---••-•---------•-••-••------------------------•-•.........--•---.............................................................
Description of Soil .__.___ yllao-- So/ ...-.-_._.._30" _
D-----+9-'vD----�-rNG'------5 ----'----------------•-•-----.---.-----------•-----------------------------------------------------.-------------•.-----.-.-.------•-
W-•-•••---------------••-•-----•--•••--------•----•-------••----•••----•••-•----•--•--•------•-•-•---•--------------------------••-----•-••-----•-....----•---•-•--•------•...------•----.........--.•--
UNature 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 Cod — The undersigned further agrees -'not to place the system in
operation until a Certificate of Compliance has b sued y it oard of healo.. � ���
).'
Sin . ............. ✓ _...
Owe
Application Approved By.---- ..% "' ......>.. ----�/ `---'-- ....
`VDate
Application Disapproved for the following reasons: ••-- --••---•-•--••-•----•--•-----••••--•-•-----•-••---•---------•-•--•------••--••--••--•...---------•--•-----
--------------•------........------......-�--...............------.....-- • • ---------------------• ------•---......---....-------------------------------------------------...... --------.......------.
Date
Permit No ... 1Z.P 6-L.YjIssued_.
---D !�®� .............
-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF.... 119- .........................................................
Ta ifiratr of Toutplittnrr
'HIS I�_XO CERTIFY, That the Individual Sewage Disposal System constructed (--T or Repaired ( )
................................................._by:....._•- ---...•....... •---•---- ,:_.................
_
has been installed in accordance with the Jprovisions of f The State Sanita Coe es in the
application for Disposal Works Construction Permit No `_< �:...'r�................... dated��- ��___:•_'�_ ��..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NO ONS D AS /C'GIJ ANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE--- ----- .............:..........-•---•--------•----•---•--------- Ins -•---- :.. ... .......... .................................
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