HomeMy WebLinkAboutApp-Permit-ComplianceNo.. ::.. � Fw3...../. 1. ....`.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
31.V 1/.-_... oF...........
Applira#inn for Dhip ii al Vorkfi Towunrtion ramit
Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal
System at:
��ENO-127- AVE, � G
....------ ------...... -------------------------------------------------------- ......
Loca ion - Address
or LotN
....
Address
Installer Address
Type of Building Size Lot. _Z__t_.... e.1 i ...Sq. feet
Dwelling —No. of Bedrooms .............. .3 ...... _.................. Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures --------------------------------------------------------------------------------•---------------------------------------------------------------•-----
Design Flow ............ ` .....................gallons per person per day. Total daily flow .............. _�3----- ..._...._...._.....gallons.
Septic Tank —Liquid'capacity10Q0__gallons Length ....... Width -_____s2 '.__ Diameter ................ Depth -..-1..._.
Disposal Trench — No ..................... Width .................... Total Length _____....._.... ... Total leaching area .................... sq. ft.
Seepage Pit No._-_-_./........... Diameter ......... 8_i . ...
_.___- Depth below inlet ............... Total leaching area. -3.00 ----- sq. ft.
Other Distribution box Dosing tank ( )
Percolation Test Results Performed by P_r___ 1' !�? e .46111 ........................... Date.--_9."__��.. ` .... � ....
Test Pit No. 1 -!<.Z -____minuteser inch Depth of Test Pit.... . -' �...._ Depth to round water! 07-
P P ground E-�tJ�Ji�z1
Test Pit No. 2................minutes per inch Depth of Test Pit -------------------- Depth to ground water. .......................
----------------------------------
-----------------------------------------------------
-----------------------
.----
Description of Soil,.O'?- ..� ..
...-L-.-- - -�t���,'c�lL � � ' - 1�.�---� �� ` �4-�-D-------------------
---------------------------------------------------------------------------------------------------- -----
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 'TTL
E, 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-. ------------------------------------------------------------------------------------ --------------------------------
Date
Application Approved B 2G -------•--------------------------------- G c
D e
Application Disapproved for the following reasons- ----------------------------------------------- ---- _------•----------- ----•------------_----------------
--------------------------------------------------------------------------------------------------------------•--------------------------------------------------------------------------..
Date
PermitNo --------------------------------------------------------- Issued .-----------------------------------•• --•------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
Tllrrtifiratle of ToutpliFatta
THIS IS TO CERTIFY, -That the IUdividual Sewage .Disposal System constructed (qu) or Repaired ( )
C
� � Installer
at j 1. .- .. - -= = = t �. ='d 'iz ..................................
. T /'_-.. _....... /_.,".i ............." _
has been installed in accordance with the prov'sions of TITLE 5 of The State Sanitary Ct, e as described in the
application for Disposal Works Construction Permit No ........ ----------- r_ `------- dated ------- <__�.'__ _._.7 __.yr .
THE ISSUANCE OF THIS CERTIFICATE SHALLANOT BE CONSTRUED AS A GUARANTEK THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE - Inspector